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Zuo C, Yan F, Wang J, Zhu Y, Luo W, Liu Y, Liang W, Yu W, Zhang J, Peng D, Ma X, Peng C. Design, synthesis, and evaluation of the novel ozagrel-paeonol codrug with antiplatelet aggregation activities as a potent anti-stroke therapeutic agent. Front Pharmacol 2024; 15:1362857. [PMID: 38567356 PMCID: PMC10985144 DOI: 10.3389/fphar.2024.1362857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction: Ischemic stroke is the second most common chronic disease worldwide and is associated with high morbidity and mortality. Thromboembolism and platelet aggregation are the most characteristic features of stroke. Other than aspirin, no standard, accepted, or effective treatment for acute ischemic stroke has been established. Consequently, it is essential to identify novel therapeutic compounds for this condition. Methods: In this study, novel ozagrel/paeonol-containing codrugs were synthesized and characterized using 1H-NMR, 13C-NMR, and mass spectroscopy. Their antiplatelet aggregation activity was evaluated, with compound PNC3 found to exhibit the best effect. Subsequently, studies were conducted to assess its neuroprotective effect, pharmacokinetic properties and model its binding mode to P2Y12 and TXA2, two proteins critical for platelet aggregation. Results: The results indicated that PNC3 has good bioavailability and exerts protective effects against oxygen-glucose deprivation injury in PC12 cells. Molecular docking analysis further demonstrated that the compound interacts with residues located in the active binding sites of the target proteins. Conclusion: The codrugs synthesized in this study display promising pharmacological activities and have the potential for development as an oral formulation.
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Affiliation(s)
- Chijing Zuo
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Fulong Yan
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Jie Wang
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Yulong Zhu
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Wenhui Luo
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Yan Liu
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Wanhui Liang
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Weidong Yu
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Jingwei Zhang
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Daiyin Peng
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
- MOE-Anhui Joint Collaborative Innovation Center for Quality Improvement of Anhui Genuine Chinese Medicinal Materials, Hefei, China
| | - Xiaodong Ma
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Can Peng
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
- MOE-Anhui Joint Collaborative Innovation Center for Quality Improvement of Anhui Genuine Chinese Medicinal Materials, Hefei, China
- Generic Technology Research Center for Anhui TCM Industry, Anhui University of Chinese Medicine, Hefei, China
- Rural Revitalization Collaborative Technical Service Center of Anhui Province, Anhui University of Chinese Medicine, Hefei, China
- Anhui Province Key Laboratory of Pharmaceutical Preparation Technology and Application, Hefei, Anhui, China
- Center for Xin’an Medicine and Modernization of Traditional Chinese Medicine of IHM, Anhui University of Chinese Medicine, Hefei, China
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Gao Y, Ma K, Zhu Z, Zhang Y, Zhou Q, Wang J, Guo X, Luo L, Wang H, Peng K, Liu M. Modified Erchen decoction ameliorates cognitive dysfunction in vascular dementia rats via inhibiting JAK2/STAT3 and JNK/BAX signaling pathways. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 114:154797. [PMID: 37037084 DOI: 10.1016/j.phymed.2023.154797] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Vascular dementia (VaD) is one of the most common clinical syndromes of progressive neurocognitive dysfunction with uncertain mechanisms. Modified Erchen decoction (MECD), developed from "Erchen decoction (ECD)" recorded in "Taiping Huimin Heji Jufang", showed a good effect in the treatment of VaD. However, its therapeutic mechanism is still unclear. PURPOSE This study aimed to elucidate the multi-target mechanisms of MECD against VaD in vivo and in vitro. METHODS VaD model was established by two-vessel obstruction (2-VO) in Sprague-Dawley rats. Six groups, including the control, 2-VO operation, MECD treatment (2.5, 5.0 and 10.0 g kg-1 d-1), donepezil hydrochloride (positive control, 0.45 g kg-1 d-1) were designed in the whole experiment. After oral administration for 4 weeks, the effects of MECD were verified by behavioral experiments, histological observation, and biochemical index analysis. The chemical profiling of MECD was performed by UHPLC-Orbitrap Fusion-HRMS, and a "compound-target-pathway" multivariate network was constructed to validate and elucidate its pharmacological mechanisms. RESULTS Compared with 2-VO group, MECD treatment significantly alleviated anxiety and improved spatial memory in VaD rats according to the open field test (OFT) and Y-maze test. A significant increase in neuron number was observed from hematoxylin and eosin (H&E) stained images in cornu ammonis 1 (CA1) of the hippocampal region after MECD treatment. On the one hand, MECD reduced the plasma levels of triglyceride (TG), low-density lipoprotein (LDL), malondialdehyde (MDA), and amyloid-beta 42 (Aβ42), and inhibited mRNA expression of interleukin-1 beta (Il-1β) and Il-6 in the hippocampus. On the other hand, superoxide dismutase (SOD) and total antioxidant capacity (T-AOC) were significantly increased after treatment with MECD. Moreover, MECD reduced the mRNA expression and protein expression of janus kinase 2 (JAK2), signal transducer and activator of transcription 3 (STAT3), c-Jun N-terminal kinase (JNK), and BCL2-associated X (BAX) in the brain of 2-VO rats. Furthermore, 71 compounds were identified from the extract of MECD. Among them, liquiritin and isochlorogenic acid C gave inhibiting effects on the mRNA expression of Jnk. In addition, liquiritin and hesperetin were conformed with the inhibition of Jak2 transcription level in vitro experiments. CONCLUSION MECD has demonstrated a significant amelioration effect on cognitive dysfunction in VaD rats via JAK2/STAT3 and JNK/BAX signaling pathways, which represents an innovative insight into the "activate blood and eliminate phlegm" theory.
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Affiliation(s)
- Yinhuang Gao
- Key Laboratory of Drug Metabolism Research and Evaluation of the State Drug Administration, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Ke Ma
- Peng Kang National Famous Traditional Chinese Medicine Expert Inheritance Studio, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Zhibo Zhu
- Peng Kang National Famous Traditional Chinese Medicine Expert Inheritance Studio, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Yan Zhang
- Key Laboratory of Drug Metabolism Research and Evaluation of the State Drug Administration, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Qiong Zhou
- Peng Kang National Famous Traditional Chinese Medicine Expert Inheritance Studio, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Jing Wang
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Xiaowen Guo
- Peng Kang National Famous Traditional Chinese Medicine Expert Inheritance Studio, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Liuting Luo
- Peng Kang National Famous Traditional Chinese Medicine Expert Inheritance Studio, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Haitao Wang
- Key Laboratory of Drug Metabolism Research and Evaluation of the State Drug Administration, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Kang Peng
- Peng Kang National Famous Traditional Chinese Medicine Expert Inheritance Studio, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China.
| | - Menghua Liu
- Key Laboratory of Drug Metabolism Research and Evaluation of the State Drug Administration, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China.
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Singla RK, Dhonchak K, Sodhi RK, Arockia Babu M, Madan J, Madaan R, Kumar S, Sharma R, Shen B. Bergenin ameliorates cognitive deficits and neuropathological alterations in sodium azide-induced experimental dementia. Front Pharmacol 2022; 13:994018. [PMID: 36249784 PMCID: PMC9556967 DOI: 10.3389/fphar.2022.994018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Bergenin, 4-O-methyl gallic acid glucoside, is a bioactive compound found in the cortex of Mallotus japonicus (L.f.) Müll.Arg. along with many other natural resources including that from Bergenia species. The present study delineates the neuroprotective potential of bergenin through the modulation of PPAR-γ receptors. Method: Dementia was induced in the Wistar rats by intraperitoneal (i.p.) administration of sodium azide (12.5 mg/kg for the first 5 days followed by 10 mg/kg for the next 9 days). The rats were then exposed to the Morris water maze test to assess the effect on cognitive abilities followed by a series of biochemical and histopathological evaluations. Results: Sodium azide-treated rats exhibited a severe deterioration of memory as suggested by poor performance in the spatial learning task in addition to the enhancement of brain acetylcholinesterase potential, oxidative stress, inflammation, and amyloid-β (Aβ) accumulation. Administration of bergenin to sodium azide-treated rats significantly recovered cognition and related biochemical variations. Further, co-administration of Bisphenol A diglycidyl ether (BADGE), a PPAR-γ antagonist with bergenin challenged its neuroprotective effects. Conclusions: The findings of our study exhibit that the cognitive restoration potential of bergenin may be attributed to its modulatory effects against cholinesterase, oxidative stress, and inflammatory markers, as well as its neuroprotective actions, thus aligning it as a possible therapy for Alzheimer’s disease-related dementia. The study also fortifies the significance of PPAR-γ receptors in dementia.
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Affiliation(s)
- Rajeev K. Singla
- Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
| | - Konika Dhonchak
- Department of Pharmacology, Chandigarh College of Pharmacy, Mohali, India
| | - Rupinder K. Sodhi
- Department of Pharmacology, Chandigarh College of Pharmacy, Mohali, India
- *Correspondence: Rupinder K. Sodhi, ; Bairong Shen,
| | - M. Arockia Babu
- Department of Pharmacology, Chandigarh College of Pharmacy, Mohali, India
| | - Jitender Madan
- National Institute of Pharmaceutical Education and Research, Hyderabad, India
| | - Reecha Madaan
- Chitkara College of Pharmacy, Chitkara University, Rajpura, Punjab, India
| | - Suresh Kumar
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, India
| | - Rohit Sharma
- Department of Rasa Shastra and Bhaishajya Kalpana, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Bairong Shen
- Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- *Correspondence: Rupinder K. Sodhi, ; Bairong Shen,
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Lansdell TA, Chambers LC, Dorrance AM. Endothelial Cells and the Cerebral Circulation. Compr Physiol 2022; 12:3449-3508. [PMID: 35766836 DOI: 10.1002/cphy.c210015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endothelial cells form the innermost layer of all blood vessels and are the only vascular component that remains throughout all vascular segments. The cerebral vasculature has several unique properties not found in the peripheral circulation; this requires that the cerebral endothelium be considered as a unique entity. Cerebral endothelial cells perform several functions vital for brain health. The cerebral vasculature is responsible for protecting the brain from external threats carried in the blood. The endothelial cells are central to this requirement as they form the basis of the blood-brain barrier. The endothelium also regulates fibrinolysis, thrombosis, platelet activation, vascular permeability, metabolism, catabolism, inflammation, and white cell trafficking. Endothelial cells regulate the changes in vascular structure caused by angiogenesis and artery remodeling. Further, the endothelium contributes to vascular tone, allowing proper perfusion of the brain which has high energy demands and no energy stores. In this article, we discuss the basic anatomy and physiology of the cerebral endothelium. Where appropriate, we discuss the detrimental effects of high blood pressure on the cerebral endothelium and the contribution of cerebrovascular disease endothelial dysfunction and dementia. © 2022 American Physiological Society. Compr Physiol 12:3449-3508, 2022.
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Affiliation(s)
- Theresa A Lansdell
- Department of Pharmacology and Toxicology, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
| | - Laura C Chambers
- Department of Pharmacology and Toxicology, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
| | - Anne M Dorrance
- Department of Pharmacology and Toxicology, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, 48824, USA
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Wei B, Wu S, Wang Z, Song W, Zhu J. Comparison of Cognitive Performance and Cardiac Function Between Three Different Rat Models of Vascular Dementia. Neuropsychiatr Dis Treat 2022; 18:19-28. [PMID: 35018098 PMCID: PMC8742620 DOI: 10.2147/ndt.s338226] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/08/2021] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Establishing an ideal animal model is essential for studying the pathogenesis, prevention and treatment of vascular dementia (VD). The present study was designed to compare the differences of behavior, cerebral blood flow (CBF), cardiac output and the levels of myocardial enzyme of three different VD rat models. METHODS The rats were randomly divided into sham-operated group (SHAM), permanent bilateral common carotid artery occlusion group (BCCAO), BCCAO combined with sodium nitroprusside (2.0mg·kg-1) group (BCCAO+2.0SNP) and BCCAO combined with sodium nitroprusside (2.5mg·kg-1) group (BCCAO+2.5SNP). After operation, Morris water maze test, echocardiographic evaluation and the measurement of CBF were performed, then the levels of myocardial enzymes in serum were assessed during euthanasia. RESULTS Compared with SHAM rats, the three VD model rats showed different degrees of cognitive impairment, lower cardiac output and CBF, and BCCAO rats showed higher levels of myocardial enzymes. Compared with BCCAO rats, the spatial learning ability of BCCAO+2.0SNP rats and BCCAO+2.5SNP rats was more severely impaired, while the levels of myocardial enzymes of BCCAO+2.0SNP rats were lower. Compared with BCCAO+2.0SNP rats, BCCAO+2.5SNP rats showed no significant difference in cognitive function and cardiac function. CONCLUSION Our present study demonstrated that all of the three different VD rat models exhibited cognitive and cardiac function impairment. The BCCAO+2.0SNP model and BCCAO+2.5SNP model damaged the spatial learning ability more seriously. The BCCAO+2.5SNP model caused more comprehensive cognitive impairment. In addition, the BCCAO+2.0SNP model and BCCAO+2.5SNP model might cause more serious damage to cardiac function.
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Affiliation(s)
- Baoyu Wei
- State Key Laboratory of Component-Based Chinese Medicine, Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, People's Republic of China
| | - Shihao Wu
- State Key Laboratory of Component-Based Chinese Medicine, Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, People's Republic of China
| | - Zhaoqi Wang
- State Key Laboratory of Component-Based Chinese Medicine, Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, People's Republic of China
| | - Wanshan Song
- Department of Acupuncture and Cerebropathy, Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300250, People's Republic of China
| | - Jinqiang Zhu
- State Key Laboratory of Component-Based Chinese Medicine, Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, People's Republic of China
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Yu Y, Wang L, Zhu X, Liu YF, Ma HY. Sodium ozagrel and atorvastatin for type 2 diabetes patients with lacunar cerebral infarction. World J Diabetes 2021; 12:2096-2106. [PMID: 35047123 PMCID: PMC8696649 DOI: 10.4239/wjd.v12.i12.2096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/15/2021] [Accepted: 12/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The main pathological factor of cerebral infarction is atherosclerosis, which is the pathological process of chronic inflammatory diseases such as vascular smooth muscle hyperplasia, inflammatory cell infiltration, extracellular matrix increase, and thrombosis. At present, the focus of clinical treatment is anti-platelet aggregation and improving blood status, and current research is limited to improving symptoms only.
AIM To observe the effect of sodium ozagrel and atorvastatin on type 2 diabetes patients with lacunar cerebral infarction.
METHODS Eighty-two patients with type 2 diabetes and lacunar cerebral infarction admitted to our hospital from January 2018 to February 2020 were equally categorized into two groups according to their treatment method. The control group was administered atorvastatin, and the observation group was administered sodium ozagrel combined with atorvastatin. The National Institutes of Health stroke scale (NIHSS) score, activities of daily living (ADL) score, blood glucose, lipid levels, inflammatory factors, high-mobility group box 1 (HMGB1) levels, paraoxonase-1 (PON-1) levels, erythrocyte sedimentation rate (ESR), and macrophage migration inhibitory factor (MIF) levels were recorded before and after treatment. The total effective rate and adverse reaction rate of the two groups were analyzed.
RESULTS The total effective rate of the observation group (94.00%) was significantly higher than that of the control group (80.00%) (χ2 = 3.998; P = 0.046). The blood glucose indexes, total cholesterol levels, triglyceride levels, low-density lipoprotein cholesterol levels, high-sensitivity C-reactive protein levels, interleukin-1β levels, tumor necrosis factor-α levels, HMGB1 Levels, ESR, MIF levels, platelet aggregation rates, and plasma viscosity of the two groups decreased after treatment; however, high-density lipoprotein cholesterol and PON-1 Levels increased after treatment. After treatment, the blood glucose indexes; blood lipid indexes; inflammatory factors; HMGB1, PON-1, and MIF levels; ESR; platelet aggregation rate; and plasma viscosity of the observation group were better than those of the control group (P < 0.05). After treatment, all patients in the observation group had higher ADL scores and lower NIHSS scores than those in the control group (P < 0.05).
CONCLUSION Sodium ozagrel with atorvastatin can reduce inflammatory reactions; regulate ESR and HMGB1, PON-1, and MIF levels; control blood glucose and lipid indexes; and alleviate nerve injury without increasing adverse effects of atorvastatin alone.
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Affiliation(s)
- You Yu
- Department of Pharmacy, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
| | - Lin Wang
- Department of Pharmacy, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
| | - Xu Zhu
- Department of Pharmacy, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
| | - Ya-Fei Liu
- Department of Pharmacy, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
| | - Hai-Ying Ma
- Department of Pharmacy, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
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Cerebralcare Granule® combined with nimodipine improves cognitive impairment in bilateral carotid artery occlusion rats by reducing lipocalin-2. Life Sci 2021; 286:120048. [PMID: 34655604 DOI: 10.1016/j.lfs.2021.120048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/01/2021] [Accepted: 10/08/2021] [Indexed: 11/21/2022]
Abstract
AIMS Clinically, Cerebralcare Granule® (CG) has been widely utilized to treat various types of headache, chronic cerebral insufficiency and other diseases, and the effect is significant. Clinical studies have shown that CG can significantly relieve vascular dementia (VaD), however, the molecular mechanisms haven't been established. To clear the therapeutic mechanisms of CG against VaD, a hypothesis was proposed that CG could treat neurovascular injury by inhibiting the production of lipocalin-2 (LCN 2). MAIN METHODS 90 dementia rats were selected by water maze test and randomly divided into 6 groups, including nimodipine (NM), CG L (low dose) (0.314 g kg-1), CG H (high dose) (0.628 g kg-1), and combined group (CG + NM). And in vitro neuronal cell OGD modeling to evaluate the effect of CG on JAK2/STAT3. KEY FINDINGS CG could significantly shorten the escape latency of two-vessel occlusion (2-VO) rats, increase their exploratory behavior, alleviate the symptoms of VaD and improve the ultrastructural pathological damage of neurovascular unit and accelerate the recovery of cerebral blood perfusion. CG combined with NM is better than NM alone. It was further showed that CG could inhibit the pathogenicity of LCN 2 through JAK2/STAT3 pathway and suppress the production of inflammatory cytokines. It plays a role in the protection of cerebral microvasculature and BBB in 2-VO rats. SIGNIFICANCE Taken together, there data has supported notion that CG can protect the integrity of cerebral blood vessels and BBB and improve cognitive impairment through mainly inhibiting LCN 2, which provides scientific evidence for clinical application.
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