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Zhang X, Li H, Wang H, Zhang Q, Deng X, Zhang S, Wang L, Guo C, Zhao F, Yin Y, Zhou T, Zhong J, Feng H, Chen W, Zhang J, Feng H, Hu R. Iron/ROS/Itga3 mediated accelerated depletion of hippocampal neural stem cell pool contributes to cognitive impairment after hemorrhagic stroke. Redox Biol 2024; 71:103086. [PMID: 38367510 PMCID: PMC10883838 DOI: 10.1016/j.redox.2024.103086] [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: 01/04/2024] [Revised: 02/11/2024] [Accepted: 02/11/2024] [Indexed: 02/19/2024] Open
Abstract
Hemorrhagic stroke, specifically intracerebral hemorrhage (ICH), has been implicated in the development of persistent cognitive impairment, significantly compromising the quality of life for affected individuals. Nevertheless, the precise underlying mechanism remains elusive. Here, we report for the first time that the accumulation of iron within the hippocampus, distal to the site of ICH in the striatum, is causally linked to the observed cognitive impairment with both clinical patient data and animal model. Both susceptibility-weighted imaging (SWI) and quantitative susceptibility mapping (QSM) demonstrated significant iron accumulation in the hippocampus of ICH patients, which is far from the actual hematoma. Logistical regression analysis and multiple linear regression analysis identified iron level as an independent risk factor with a negative correlation with post-ICH cognitive impairment. Using a mouse model of ICH, we demonstrated that iron accumulation triggers an excessive activation of neural stem cells (NSCs). This overactivation subsequently leads to the depletion of the NSC pool, diminished neurogenesis, and the onset of progressive cognitive dysfunction. Mechanistically, iron accumulation elevated the levels of reactive oxygen species (ROS), which downregulated the expression of Itga3. Notably, pharmacological chelation of iron accumulation or scavenger of aberrant ROS levels, as well as conditionally overexpressed Itga3 in NSCs, remarkably attenuated the exhaustion of NSC pool, abnormal neurogenesis and cognitive decline in the mouse model of ICH. Together, these results provide molecular insights into ICH-induced cognitive impairment, shedding light on the value of maintaining NSC pool in preventing cognitive dysfunction in patients with hemorrhagic stroke or related conditions.
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Affiliation(s)
- Xuyang Zhang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Huanhuan Li
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Haomiao Wang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Qian Zhang
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Xueyun Deng
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China; Department of Neurosurgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong, 637000, China
| | - Shuixian Zhang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Long Wang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Chao Guo
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Fengchun Zhao
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Yi Yin
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Tengyuan Zhou
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Jun Zhong
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Hui Feng
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Wei Chen
- Department of Radiology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jun Zhang
- Department of Neurobiology, College of Basic Medical Sciences, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Hua Feng
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China
| | - Rong Hu
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), 400038, Chongqing, China.
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Yan G, Zhang X, Li H, Guo Y, Yong VW, Xue M. Anti-oxidant effects of cannabidiol relevant to intracerebral hemorrhage. Front Pharmacol 2023; 14:1247550. [PMID: 37841923 PMCID: PMC10568629 DOI: 10.3389/fphar.2023.1247550] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
Intracerebral hemorrhage (ICH) is a subtype of stroke with a high mortality rate. Oxidative stress cascades play an important role in brain injury after ICH. Cannabidiol, a major non-psychotropic phytocannabinoids, has drawn increasing interest in recent years as a potential therapeutic intervention for various neuropsychiatric disorders. Here we provide a comprehensive review of the potential therapeutic effects of cannabidiol in countering oxidative stress resulting from ICH. The review elaborates on the various sources of oxidative stress post-ICH, including mitochondrial dysfunction, excitotoxicity, iron toxicity, inflammation, and also highlights cannabidiol's ability to inhibit ROS/RNS generation from these sources. The article also delves into cannabidiol's role in promoting ROS/RNS scavenging through the Nrf2/ARE pathway, detailing both extranuclear and intranuclear regulatory mechanisms. Overall, the review underscores cannabidiol's promising antioxidant effects in the context of ICH and suggests its potential as a therapeutic option.
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Affiliation(s)
- Gaili Yan
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, Henan, China
| | - Xiangyu Zhang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, Henan, China
| | - Hongmin Li
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, Henan, China
| | - Yan Guo
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, Henan, China
| | - V. Wee Yong
- Hotchkiss Brain Institute and Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mengzhou Xue
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, Henan, China
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Lai JHC, Liu J, Yang T, Huang J, Liu Y, Chen Z, Lee Y, Leung GKK, Chan KWY. Chemical Exchange Saturation Transfer Magnetic Resonance Imaging for Longitudinal Assessment of Intracerebral Hemorrhage and Deferoxamine Treatment at 3T in a Mouse Model. Stroke 2023; 54:255-264. [PMID: 36416125 DOI: 10.1161/strokeaha.122.040830] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Noninvasive imaging of molecular alterations after intracerebral hemorrhage (ICH) could provide valuable information to guide and monitor treatments. Chemical exchange saturation transfer (CEST) magnetic resonance imaging has demonstrated promises in identifying proliferation, necrosis, and changes in cellularity in brain tumors. Here, we applied CEST magnetic resonance imaging to monitor molecular changes in hematoma without and with treatment noninvasively over 2 weeks at 3T using endogenous contrast. METHODS CEST contrast related to proteins at 3.5 ppm (amide proton transfer) and proteins/lipids at -3.5 ppm (relayed nuclear overhauser effect [rNOE]) were examined over 14 days in a collagenase-induced ICH mouse model. Imaging findings were validated with immunohistochemistry based on the ICH neuropathology. We also examined iron-containing phantoms that mimicked iron concentrations in hematoma to ensure the iron will not attenuate the CEST contrast during disease progression. Based on the validity of the CEST contrast of hematoma, we further examined related molecular alterations under iron-chelation treatment with deferoxamine. RESULTS We observed the temporal and spatial differences of CEST contrasts between rNOE at -3.5 ppm and amide proton transfer at 3.5 ppm, in which the core and perihematoma could be identified by rNOE on day 3 and day 14, and amide proton transfer on day 1, day 7, and day 14. Moreover, we observed a 25.7% significant reduction (P<0.05) of rNOE contrast after deferoxamine treatment to the ICH mice on day 3, which was not observable in amide proton transfer contrast. Our histology data indicated that rNOE primarily correlated with the myelin pathology, and amide proton transfer could reflect the cellularity increase at hematoma up to day 7. CONCLUSIONS Significant rNOE changes correlated well with histologic findings, especially myelin lipids, and regional characteristics in hematoma indicate the uniqueness of CEST magnetic resonance imaging in monitoring molecular changes during ICH and treatment.
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Affiliation(s)
- Joseph H C Lai
- Department of Biomedical Engineering (J.H.C.L., J.H., Y. Liu, Z.C., K.W.Y.C.), City University of Hong Kong
| | - Jiaxin Liu
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong (J.L., T.Y., Y. Liu)
| | - Tian Yang
- Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong (J.L., T.Y., Y. Liu)
| | - Jianpan Huang
- Department of Biomedical Engineering (J.H.C.L., J.H., Y. Liu, Z.C., K.W.Y.C.), City University of Hong Kong
| | - Yang Liu
- Department of Biomedical Engineering (J.H.C.L., J.H., Y. Liu, Z.C., K.W.Y.C.), City University of Hong Kong.,Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong (J.L., T.Y., Y. Liu)
| | - Zilin Chen
- Department of Biomedical Engineering (J.H.C.L., J.H., Y. Liu, Z.C., K.W.Y.C.), City University of Hong Kong
| | - Youngjin Lee
- Department of Neuroscience (Y. Lee), City University of Hong Kong
| | | | - Kannie W Y Chan
- Department of Biomedical Engineering (J.H.C.L., J.H., Y. Liu, Z.C., K.W.Y.C.), City University of Hong Kong.,Tung Biomedical Sciences Centre (K.W.Y.C.), City University of Hong Kong.,Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD (K.W.Y.C.).,City University of Hong Kong Shenzhen Research Institute, China (K.W.Y.C.).,Hong Kong Centre for Cerebro-Cardiovascular Health Engineering (K.W.Y.C.)
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Dai Y, Hu L. HSPB1 overexpression improves hypoxic-ischemic brain damage by attenuating ferroptosis in rats through promoting G6PD expression. J Neurophysiol 2022; 128:1507-1517. [PMID: 36321738 DOI: 10.1152/jn.00306.2022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Heat-shock protein B (HSPB1) has a neuroprotective effect on brain injury and is a negative regulator of ferroptosis. Therefore, we infer that HSPB1 plays a protective role in hypoxic-ischemic (HI) brain damage by inhibiting ferroptosis. A neonatal rat model of hypoxic-ischemic (HI) brain damage was established. HSPB1 overexpression plasmid and the negative control were injected into the lateral ventricle of rats 48 h before HI brain damage surgery. HSPB1 and glucose-6-phosphate dehydrogenase (G6PD) levels, infarction rate, iron accumulation, apoptosis, and ferroptosis-related markers were estimated with the assistance of qRT-PCR, 2,3,5-triphenyl tetrazolium chloride (TTC) staining, Prussian blue staining, iron assay kit, TUNEL staining, and Western blot. In vitro, after transfection, HSPB1 and G6PD levels, oxygen-glucose deprivation (OGD)-mediated hippocampal neuron cell viability, apoptosis, iron content, and ferroptosis-related markers were assessed using qRT-PCR, MTT, flow cytometry, iron assay kit, and Western blot. HSPB1 and G6PD were overexpressed in the hippocampus tissues of HI rats. High expression of HSPB1 in HI rats lessened infarction rate and ferritin level, hindered iron accumulation and apoptosis, and promoted GPX4, SLC7A11, and TFR1 levels. In OGD-mediated hippocampal neuron cells, HSPB1 upregulation intensified the viability and repressed apoptosis and ferroptosis, whereas G6PD silencing reversed the effects of HSPB1 upregulation. We documented that HSPB1 overexpression unleashes neuroprotective effects via modulating G6PD expression, which offers a novel target for the prevention and treatment of HI brain damage.NEW & NOTEWORTHY HSPB1 and G6PD were overexpressed in the hippocampus tissues of HI rats. High expression of HSPB1 in HI rats mitigated infarction rate and iron accumulation. HSPB1 overexpression reduced ferritin level, attenuated apoptosis, yet augmented GPX4, SLC7A11, and TFR1 levels in the hippocampus tissues of HI rats. G6PD deletion impaired the protective role of HSPB1 overexpression against HI brain damage-induced ferroptosis.
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Affiliation(s)
- Yi Dai
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, People's Republic of China
| | - Lan Hu
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, People's Republic of China
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Li G, Wang S, Xiong Y, Gu H, Jiang Y, Yang X, Wang C, Wang C, Li Z, Zhao X. Higher fasting blood glucose was associated with worse in-hospital clinical outcomes in patients with primary intracerebral hemorrhage: From a large-scale nationwide longitudinal registry. CNS Neurosci Ther 2022; 28:2260-2267. [PMID: 36152306 PMCID: PMC9627374 DOI: 10.1111/cns.13972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/19/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Studies that investigated the relationship between fasting blood glucose (FBG) and intracerebral hemorrhage (ICH) outcomes were insufficient. AIM We aimed to investigate the association between FBG level and in-hospital clinical outcomes in patients with primary ICH. RESULTS A total of 34,507 patients were enrolled in the final study. Compared with the reference group, the ≥6.1 and <7 mmol/L group showed nonsignificant higher in-hospital mortality (adjusted odds ratio [OR] 1.20, 95% confidence interval [CI] 0.69-2.11, p = 0.52), and a significant higher proportion of intracranial hematoma evacuation (adjusted OR 1.56, 95% CI 1.26-1.92, p < 0.001). The ≥7 mmol/L group showed both significant higher in-hospital mortality (adjusted OR 2.08, 95% CI 1.42-3.04, p = 0.52) and a significant higher proportion of intracranial hematoma evacuation (adjusted OR 2.09, 95% CI 1.78-2.47, p < 0.001). CONCLUSION Higher FBG level was correlated with both higher mortality and proportion of evacuation of intracranial hematoma.
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Affiliation(s)
- Guangshuo Li
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Shang Wang
- Neurocardiology Center, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,Chinese Institute for Brain ResearchBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Yingyu Jiang
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Xin Yang
- China National Clinical Research Center for Neurological DiseasesBeijingChina,National Center for Healthcare Quality Management in Neurological DiseasesBeijingChina
| | - Chunjuan Wang
- China National Clinical Research Center for Neurological DiseasesBeijingChina,National Center for Healthcare Quality Management in Neurological DiseasesBeijingChina
| | - Chuanying Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,Chinese Institute for Brain ResearchBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijingChina
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Li J, Luo D, Peng F, Kong Q, Liu H, Chen M, Tong L, Gao F. ANAID-ICH nomogram for predicting unfavorable outcome after intracerebral hemorrhage. CNS Neurosci Ther 2022; 28:2066-2075. [PMID: 36000537 PMCID: PMC9627367 DOI: 10.1111/cns.13941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/21/2022] [Accepted: 07/31/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Diffusion-weighted imaging lesions (DWILs) are associated with unfavorable outcome in intracerebral hemorrhage (ICH). We proposed a novel predictive nomogram incorporating DWILs. METHODS A total of 738 patients with primary ICH in a tertiary hospital were prospectively enrolled as a training cohort. DWILs were defined as remote focal hyperintensities on DWI corresponding to low intensities on apparent diffusion coefficient images and remote from the focal hematoma. The outcome of interest was modified Rankin Scale scores of 4-6 at 90 days after onset. Multivariate logistic regression was used to construct a nomogram. Model performance was tested in the training cohort and externally validated with respect to discrimination, calibration, and clinical usefulness in another institute. Additionally, the nomogram was compared with the ICH score in terms of predictive ability. RESULTS Overall, 153 (20.73%) and 23 (15.54%) patients developed an unfavorable outcome in the training and validation cohorts, respectively. The multivariate analysis revealed that age, National Institutes of Health Stroke Scale (NIHSS) score, anemia, infratentorial location, presence of DWILs, and prior ICH were associated with unfavorable outcome. Our ANAID-ICH nomogram was constructed according to the aforementioned variables; the area under the receiver operating characteristic curve was 0.842 and 0.831 in the training and validation sets, respectively. With regard to the 90-day outcome, the nomogram showed a significantly higher predictive value than the ICH score in both cohorts. CONCLUSIONS The ANAID-ICH nomogram comprising age, NIHSS score, anemia, infratentorial location, presence of DWILs, and prior ICH may facilitate the identification of patients at higher risk for an unfavorable outcome.
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Affiliation(s)
- Jiawen Li
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Dong Luo
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Feifei Peng
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Qi Kong
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Huawei Liu
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Meiyuan Chen
- Department of NeurologyThe Affiliated Hospital of Hangzhou Normal UniversityHangzhouChina
| | - Lusha Tong
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Feng Gao
- Department of Neurology, The Second Affiliated HospitalZhejiang University School of MedicineHangzhouChina
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Wei Y, Song X, Gao Y, Gao Y, Li Y, Gu L. Iron toxicity in intracerebral hemorrhage: Physiopathological and therapeutic implications. Brain Res Bull 2021; 178:144-154. [PMID: 34838852 DOI: 10.1016/j.brainresbull.2021.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 01/09/2023]
Abstract
Intracerebral hemorrhage (ICH)-induced brain injury is a continuous pathological process that involves the deterioration of neurological functions, such as sensory, cognitive or motor functions. Cytotoxic byproducts of red blood cell lysis, especially free iron, appear to be a significant pathophysiologic mechanism leading to ICH-induced injury. Free iron has a crucial role in secondary brain injury after ICH. Chelating iron may attenuate iron-induced neurotoxicity and may be developed as a therapeutic candidate for ICH treatment. In this review, we focused on the potential role of iron toxicity in ICH-induced injury and iron chelation therapy in the management of ICH. It will hopefully advance our understanding of the pathogenesis of ICH and lead to new approaches for treatment.
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Affiliation(s)
- Yufei Wei
- Department of Internal Neurology, First Affiliated Hospital, Guangxi University of Chinese Medicine, Nanning, Guangxi 530000, China
| | - Xiaoxiao Song
- Department of Internal Neurology, First Affiliated Hospital, Guangxi University of Chinese Medicine, Nanning, Guangxi 530000, China
| | - Ying Gao
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100010, China
| | - Yonghong Gao
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing 100010, China
| | - Yuanyuan Li
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing 100010, China
| | - Lian Gu
- Department of Internal Neurology, First Affiliated Hospital, Guangxi University of Chinese Medicine, Nanning, Guangxi 530000, China.
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