Response to Korley et al.: Progesterone Treatment Does Not Decrease Serum Levels of Biomarkers of Glial and Neuronal Cell Injury in Moderate and Severe TBI Subjects: A Secondary Analysis of the Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (ProTECT) III Trial (DOI: 10.1089/neu.2020.7072)

Progesterone: A Neuroprotective Steroid of the Intestine

The enteric nervous system (ENS) is an intrinsic network of neuronal ganglia in the intestinal tube with about 100 million neurons located in the myenteric plexus and submucosal plexus. These neurons being affected in neurodegenerative diseases, such as Parkinson's disease, before pathological changes in the central nervous system (CNS) become detectable is currently a subject of discussion. Understanding how to protect these neurons is, therefore, particularly important. Since it has already been shown that the neurosteroid progesterone mediates neuroprotective effects in the CNS and PNS, it is now equally important to see whether progesterone has similar effects in the ENS. For this purpose, the RT-qPCR analyses of laser microdissected ENS neurons were performed, showing for the first time the expression of the different progesterone receptors (PR-A/B; mPRa, mPRb, PGRMC1) in rats at different developmental stages. This was also confirmed in ENS ganglia using immunofluorescence techniques and confocal laser scanning microscopy. To analyze the potential neuroprotective effects of progesterone in the ENS, we stressed dissociated ENS cells with rotenone to induce damage typical of Parkinson's disease. The potential neuroprotective effects of progesterone were then analyzed in this system. Treatment of cultured ENS neurons with progesterone reduced cell death by 45%, underscoring the tremendous neuroprotective potential of progesterone in the ENS. The additional administration of the PGRMC1 antagonist AG205 abolished the observed effect, indicating the crucial role of PGRMC1 with regard to the neuroprotective effect of progesterone.

Effects of Progesterone on Preclinical Animal Models of Traumatic Brain Injury: Systematic Review and Meta-analysis

Since the publication of two phase III clinical trials not supporting the use of progesterone in patients with traumatic brain injury (TBI), several possible explanations have been postulated, including limitations in the analysis of results from preclinical evidence. Therefore, to address this question, a systematic review and meta-analysis was performed to evaluate the effects of progesterone as a neuroprotective agent in preclinical animal models of TBI. A total of 48 studies were included for review: 29 evaluated brain edema, 21 evaluated lesion size, and 0 studies reported the survival rate. In the meta-analysis, it was found that progesterone reduced brain edema (effect size - 1.73 [- 2.02, - 1.44], p < 0.0001) and lesion volume (effect size - 0.40 [- 0.65, - 0.14], p = 0.002). Lack of details in the studies hindered the assessment of risk of bias (through the SYRCLE tool). A funnel plot asymmetry was detected, suggesting a possible publication bias. In conclusion, preclinical studies show that progesterone has an anti-edema effect in animal models of TBI, decreasing lesion volume or increasing remaining tissue. However, more studies are needed using assessing methods with lower risk of histological artifacts.