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Custodia A, Ouro A, Sargento-Freitas J, Aramburu-Núñez M, Pías-Peleteiro JM, Hervella P, Rosell A, Ferreira L, Castillo J, Romaus-Sanjurjo D, Sobrino T. Unraveling the potential of endothelial progenitor cells as a treatment following ischemic stroke. Front Neurol 2022; 13:940682. [PMID: 36158970 PMCID: PMC9492921 DOI: 10.3389/fneur.2022.940682] [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: 05/10/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Ischemic stroke is becoming one of the most common causes of death and disability in developed countries. Since current therapeutic options are quite limited, focused on acute reperfusion therapies that are hampered by a very narrow therapeutic time window, it is essential to discover novel treatments that not only stop the progression of the ischemic cascade during the acute phase, but also improve the recovery of stroke patients during the sub-acute or chronic phase. In this regard, several studies have shown that endothelial progenitor cells (EPCs) can repair damaged vessels as well as generate new ones following cerebrovascular damage. EPCs are circulating cells with characteristics of both endothelial cells and adult stem cells presenting the ability to differentiate into mature endothelial cells and self-renew, respectively. Moreover, EPCs have the advantage of being already present in healthy conditions as circulating cells that participate in the maintenance of the endothelium in a direct and paracrine way. In this scenario, EPCs appear as a promising target to tackle stroke by self-promoting re-endothelization, angiogenesis and vasculogenesis. Based on clinical data showing a better neurological and functional outcome in ischemic stroke patients with higher levels of circulating EPCs, novel and promising therapeutic approaches would be pharmacological treatment promoting EPCs-generation as well as EPCs-based therapies. Here, we will review the latest advances in preclinical as well as clinical research on EPCs application following stroke, not only as a single treatment but also in combination with new therapeutic approaches.
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Affiliation(s)
- Antía Custodia
- NeuroAging Laboratory (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Alberto Ouro
- NeuroAging Laboratory (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - João Sargento-Freitas
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
- Centro Neurociências e Biologia Celular, Coimbra, Portugal
| | - Marta Aramburu-Núñez
- NeuroAging Laboratory (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Juan Manuel Pías-Peleteiro
- NeuroAging Laboratory (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Pablo Hervella
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Anna Rosell
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lino Ferreira
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
- Centro Neurociências e Biologia Celular, Coimbra, Portugal
- CNC-Center for Neuroscience and Cell Biology, CIBB-Centre for Innovative Biomedicine and Biotechnology, UC, Biotech Parque Tecnológico de Cantanhede, University of Coimbra, Coimbra, Portugal
| | - José Castillo
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Daniel Romaus-Sanjurjo
- NeuroAging Laboratory (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- *Correspondence: Daniel Romaus-Sanjurjo
| | - Tomás Sobrino
- NeuroAging Laboratory (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- Tomás Sobrino
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Honig A, Percy J, Sepehry AA, Gomez AG, Field TS, Benavente OR. Hemorrhagic Transformation in Acute Ischemic Stroke: A Quantitative Systematic Review. J Clin Med 2022; 11:jcm11051162. [PMID: 35268253 PMCID: PMC8910828 DOI: 10.3390/jcm11051162] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
The prevalence and risk factors of hemorrhagic transformation (HT) after acute ischemic stroke HT have not been adequately delineated. We performed a systematic review and meta-analysis to identify English-language prospective observational MEDLINE and EMBASE-listed reports of acute ischemic stroke with HT published from 1985–2017. Studies that used the ECASS-2 definitions of hemorrhagic transformation subtypes, hemorrhagic infarction (HI), and parenchymal hematoma (PH) were included. Patients treated with intravenous thrombolysis with tissue plasminogen activator (IV-tPA) were compared with those who did not receive thrombolysis. A total of 65 studies with 17,259 patients met inclusion criteria. Overall, HT prevalence was 27%; 32% in patients receiving IV-tPA vs. 20% in those without. Overall PH prevalence was 9%; 12% in IV-tPA treated patients vs. 5% in those without. HT was associated with a history of atrial fibrillation (OR 2.94) and use of anticoagulants (OR 2.47). HT patients had higher NIHSS (Hedge’s-G 0.96) and larger infarct volume (diffusion-weighted MRI, Hedge’s-G 0.8). In IV-tPA treated patients, PH correlated with antiplatelet (OR 3) and statin treatment (OR 4). HT (OR 3) and PH (OR 8) were associated with a poor outcome at 90-day (mRS 5–6). Hemorrhagic transformation is a frequent complication of acute ischemic stroke and is associated with poor outcome. Recognition of risk factors for HT and PH may reduce their incidence and severity.
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Affiliation(s)
- Asaf Honig
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
- Correspondence:
| | - Jennifer Percy
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Amir A. Sepehry
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
- Clinical Psychology Program, Adler University, Vancouver, BC V6B 3J5, Canada
| | - Alejandra G. Gomez
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Thalia S. Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Oscar R. Benavente
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
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Dias A, Silva I, Pinto IM, Maia LF. Timely and Blood-Based Multiplex Molecular Profiling of Acute Stroke. Life (Basel) 2021; 11:816. [PMID: 34440560 PMCID: PMC8398526 DOI: 10.3390/life11080816] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 12/12/2022] Open
Abstract
Stroke is a leading cause of death and disability in the world. To address such a problem, early diagnosis and tailored acute treatment represent one of the major priorities in acute stroke care. Since the efficacy of reperfusion treatments is highly time-dependent, there is a critical need to optimize procedures for faster and more precise diagnosis. We provide a concise review of the most relevant and well-documented blood-protein biomarkers that exhibit greater potential for translational to clinical practice in stroke differential diagnosis and to differentiate ischemic stroke from hemorrhagic stroke, followed by an overview of the most recent point-of-care technological approaches to address this problem. The integration of fluid-based biomarker profiling, using point-of-care biosensors with demographic, clinical, and neuroimaging parameters in multi-dimensional clinical decision-making algorithms, will be the next step in personalized stroke care.
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Affiliation(s)
- Alexandre Dias
- Department of Neurology, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-001 Porto, Portugal; (A.D.); (I.S.)
- Portugal and Ipatimup—Institute of Molecular Pathology and Immunology, University of Porto, 4200-135 Porto, Portugal
| | - Isabel Silva
- Department of Neurology, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-001 Porto, Portugal; (A.D.); (I.S.)
- Portugal and Molecular Neurobiology, IBMC—Instituto de Biologia Molecular e Celular, University of Porto, 4200-135 Porto, Portugal
| | - Inês Mendes Pinto
- International Iberian Nanotechnology Laboratory, 4715-330 Braga, Portugal
| | - Luís F. Maia
- Department of Neurology, Centro Hospitalar Universitário do Porto (CHUPorto), 4099-001 Porto, Portugal; (A.D.); (I.S.)
- Portugal and Molecular Neurobiology, IBMC—Instituto de Biologia Molecular e Celular, University of Porto, 4200-135 Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, University of Porto (ICBAS-UP), 4050-313 Porto, Portugal
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Wall A, Anger O, Jood K, Blomstrand C, Andreasson U, Blennow K, Zetterberg H, Isgaard J, Jern C, Åberg ND, Svensson J. Circulating granulocyte colony-stimulating factor and functional outcome after ischemic stroke: an observational study. Neurol Res 2021; 43:1013-1022. [PMID: 34253146 DOI: 10.1080/01616412.2021.1948766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objectives: While granulocyte colony-stimulating factor (G-CSF) has shown beneficial effects in experimental ischemic stroke (IS), these effects have not been reproduced clinically. Small-to-medium-sized observational studies have reported varying associations for G-CSF with stroke severity and post-stroke functional outcome, prompting their investigation in a larger study.Methods: Endogenous serum G-CSF (S-GCSF) was measured in the acute phase and after 3 months in patients with IS (N = 435; 36% females; mean age, 57 years) from the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). Stroke severity was scored according to the National Institutes of Health Stroke Scale (NIHSS), and the modified Rankin Scale (mRS) assessed functional outcomes at 3-month and 2-year post-stroke. Correlation and logistic regression analyses with confounder adjustments assessed the relationships.Results: The acute S-GCSF level was 23% higher than at 3-month post-stroke (p < 0.001). Acute G-CSF correlated weakly with stroke severity quintiles (r = 0.12, p = 0.013) and with high-sensitivity C-reactive protein (r = 0.29, p < 0.001). The association between S-GCSF (as quintiles, q) and poor functional outcome at 3 months (mRS 3-6; S-GCSF-q5 vs. S-GCSF-q1, age- and sex-adjusted odds ratio: 4.27, 95% confidence interval: 1.82-9.99; p = 0.001) withstood adjustment for cardiovascular risk factors and stroke subtype, but not additional correction for stroke severity. Post-stroke changes in S-GSCF and absolute 3-month S-GCSF were not associated with 3-month or 2-year functional outcomes.Discussion: Early post-stroke S-GCSF is increased in severe IS and associated with 3-month poor functional outcomes. The change in S-GCSF and the 3-month S-GCSF appear to be less-important, and S-GCSF likely reflects inflammation in large infarctions.
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Affiliation(s)
- Alexander Wall
- Department of Internal Medicine, Institute of Medicine, the Sahlgrenska Academy at the University of Gothenburg, Sweden.,Department of Acute Medicine and Geriatrics (Su/Sahlgrenska), Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olof Anger
- Department of Internal Medicine, Institute of Medicine, the Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Christian Blomstrand
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden.,Stroke Centre West, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Ulf Andreasson
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, UCL, Gower St., London, UK
| | - Jörgen Isgaard
- Department of Internal Medicine, Institute of Medicine, the Sahlgrenska Academy at the University of Gothenburg, Sweden.,Department of Acute Medicine and Geriatrics (Su/Sahlgrenska), Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christina Jern
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden.,Department of Clinical Pathology and Genetics, Institute of Biomedicine, the Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - N David Åberg
- Department of Internal Medicine, Institute of Medicine, the Sahlgrenska Academy at the University of Gothenburg, Sweden.,Department of Acute Medicine and Geriatrics (Su/Sahlgrenska), Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Svensson
- Department of Internal Medicine, Institute of Medicine, the Sahlgrenska Academy at the University of Gothenburg, Sweden
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Point-of-care quantification of serum cellular fibronectin levels for stratification of ischemic stroke patients. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2020; 30:102287. [DOI: 10.1016/j.nano.2020.102287] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 11/17/2022]
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Piccardi B, Biagini S, Iovene V, Palumbo V. Blood Biomarkers of Parenchymal Damage in Ischemic Stroke Patients Treated With Revascularization Therapies. Biomark Insights 2019; 14:1177271919888225. [PMID: 31903021 PMCID: PMC6931146 DOI: 10.1177/1177271919888225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 10/20/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose Postischemic reperfusion injury may exacerbate cerebral damage and capillary dysfunction, leading to brain edema (BE), hemorrhagic transformation (HT), necrosis, and injury from free radicals with subsequent infarct growth (IG). Several plasmatic biomarkers involved in the ischemic cascade have been studied in relation to radiological and clinical outcomes of reperfusion injury in ischemic stroke with heterogeneous results. This article provides a brief overview of the contribution of circulating biomarkers to the pathophysiology of parenchymal damage in ischemic stroke patients treated with revascularization therapies. Methods We included full reports with measurements of plasma markers in patients with acute ischemic stroke treated with revascularization therapies. Findings Our research included a large number of observational studies investigating a possible role of circulating biomarkers in the development of parenchymal damage after acute stroke treatments. To make the results clearer, we divided the review in 4 sections, exploring the relation of different biomarkers with each of the indicators of parenchymal damage (HT, BE, IG, recanalization). Discussion and conclusion Definite conclusions are difficult to draw because of heterogeneity across studies. However, our review seems to confirm an association between some circulating biomarkers (particularly matrix metalloproteinase-9) and occurrence of parenchymal damage in ischemic stroke patients treated with revascularization therapies.
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Affiliation(s)
- Benedetta Piccardi
- Benedetta Piccardi, Stroke Unit, Careggi
University Hospital, Largo Brambilla, 3, 50134 Florence, Italy.
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7
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Ouk T, Potey C, Maestrini I, Petrault M, Mendyk AM, Leys D, Bordet R, Gautier S. Neutrophils in tPA-induced hemorrhagic transformations: Main culprit, accomplice or innocent bystander? Pharmacol Ther 2019; 194:73-83. [DOI: 10.1016/j.pharmthera.2018.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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8
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Knecht T, Borlongan C, Dela Peña I. Combination therapy for ischemic stroke: Novel approaches to lengthen therapeutic window of tissue plasminogen activator. Brain Circ 2018; 4:99-108. [PMID: 30450415 PMCID: PMC6187940 DOI: 10.4103/bc.bc_21_18] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/29/2018] [Accepted: 09/10/2018] [Indexed: 12/24/2022] Open
Abstract
Tissue plasminogen activator (tPA) thrombolysis continues to be the gold standard therapy for ischemic stroke. Due to the time-limited treatment window, within 4.5 h of stroke onset, and a variety of potentially deadly complications related to delayed administration, particularly hemorrhagic transformation (HT), clinical use of tPA is limited. Combination therapies with other interventions, drug or nondrug, have been hypothesized as a logical approach to enhancing tPA effectiveness. Here, we discuss various potential pharmacological and nondrug treatments to minimize adverse effects, primarily HT, associated with delayed tPA administration. Pharmacological interventions include many that support the integrity of the blood–brain barrier (i.e., atorvastatin, batimastat, candesartan, cilostazol, fasudil, and minocycline), promote vascularization and preserve cerebrovasculature (i.e., coumarin derivative IMM-H004 and granulocyte-colony stimulating factor), employing other mechanisms of action (i.e., oxygen transporters and ascorbic acid). Nondrug treatments are comprised of stem cell transplantation and gas therapies with multi-faceted approaches. Combination therapy with tPA and the aforementioned treatments demonstrated promise for mitigating the adverse complications associated with delayed tPA treatment and rescuing stroke-induced behavioral deficits. Therefore, the conjunctive therapy method is a novel therapeutic approach that can attempt to minimize the limitations of tPA treatment and possibly increase the therapeutic window for ischemic stroke treatment.
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Affiliation(s)
- Talia Knecht
- Department of Pharmaceutical and Administrative Sciences, School of Pharmacy, Loma Linda University, Loma Linda, CA, USA
| | - Cesar Borlongan
- Department of Neurosurgery and Brain Repair, Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Ike Dela Peña
- Department of Pharmaceutical and Administrative Sciences, School of Pharmacy, Loma Linda University, Loma Linda, CA, USA
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9
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Adjunctive Therapy Approaches for Ischemic Stroke: Innovations to Expand Time Window of Treatment. Int J Mol Sci 2017; 18:ijms18122756. [PMID: 29257093 PMCID: PMC5751355 DOI: 10.3390/ijms18122756] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/12/2017] [Accepted: 12/16/2017] [Indexed: 12/18/2022] Open
Abstract
Tissue plasminogen activator (tPA) thrombolysis remains the gold standard treatment for ischemic stroke. A time-constrained therapeutic window, with the drug to be given within 4.5 h after stroke onset, and lethal side effects associated with delayed treatment, most notably hemorrhagic transformation (HT), limit the clinical use of tPA. Co-administering tPA with other agents, including drug or non-drug interventions, has been proposed as a practical strategy to address the limitations of tPA. Here, we discuss the pharmacological and non-drug approaches that were examined to mitigate the complications-especially HT-associated with delayed tPA treatment. The pharmacological treatments include those that preserve the blood-brain barrier (e.g., atovarstatin, batimastat, candesartan, cilostazol, fasudil, minocycline, etc.), enhance vascularization and protect the cerebrovasculature (e.g., coumarin derivate IMM-H004 and granulocyte-colony stimulating factor (G-CSF)), and exert their effects through other modes of action (e.g., oxygen transporters, ascorbic acid, etc.). The non-drug approaches include stem cell treatments and gas therapy with multi-pronged biological effects. Co-administering tPA with the abovementioned therapies showed promise in attenuating delayed tPA-induced side effects and stroke-induced neurological and behavioral deficits. Thus, adjunctive treatment approach is an innovative therapeutic modality that can address the limitations of tPA treatment and potentially expand the time window for ischemic stroke therapy.
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Lu G, He Q, Shen Y, Cao F. Potential biomarkers for predicting hemorrhagic transformation of ischemic stroke. Int J Neurosci 2017; 128:79-89. [PMID: 28726570 DOI: 10.1080/00207454.2017.1349766] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Reperfusion therapy contributes to better clinical outcomes in patients with acute ischemic stroke but carries a more significant risk of hemorrhagic transformation (HT) compared to supportive care. Once HT occurs, the outcome is usually poor and this causes a dilemma in the treatment of ischemic stroke. Consequently, early prediction of HT would be extremely helpful for guiding precise treatment of ischemic stroke. In this review, we focus on summarizing biomarkers of HT and elucidating possible mechanisms so as to identify potential biomarkers for predicting HT.
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Affiliation(s)
- Guanfeng Lu
- a Department of Neurology, Union Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan 430022 , China
| | - Quanwei He
- a Department of Neurology, Union Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan 430022 , China
| | - Yan Shen
- a Department of Neurology, Union Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan 430022 , China
| | - Fei Cao
- a Department of Neurology, Union Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan 430022 , China
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Peña ID, Borlongan C, Shen G, Davis W. Strategies to Extend Thrombolytic Time Window for Ischemic Stroke Treatment: An Unmet Clinical Need. J Stroke 2017; 19:50-60. [PMID: 28178410 PMCID: PMC5307939 DOI: 10.5853/jos.2016.01515] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/05/2017] [Accepted: 01/05/2017] [Indexed: 12/13/2022] Open
Abstract
To date, reperfusion with tissue plasminogen activator (tPA) remains the gold standard treatment for ischemic stroke. However, when tPA is given beyond 4.5 hours of stroke onset, deleterious effects of the drug ensue, especially, hemorrhagic transformation (HT), which causes the most significant morbidity and mortality in stroke patients. An important clinical problem at hand is to develop strategies that will enhance the therapeutic time window for tPA therapy and reduce the adverse effects (especially HT) of delayed tPA treatment. We reviewed the pharmacological agents which reduced the risk of HT associated with delayed (beyond 4.5 hours post-stroke) tPA treatment in preclinical studies, which we classified into those that putatively preserve the blood-brain barrier (e.g., minocycline, cilostazol, fasudil, candesartan, and bryostatin) and/or enhance vascularization and protect the cerebrovasculature (e.g., coumarin derivate IMM-H004 and granulocyte colony-stimulating factor). Recently, other new therapeutic modalities (e.g., oxygen transporters) have been reported which improved delayed tPA-associated outcomes by acting through other mechanisms. While the above-mentioned interventions unequivocally reduced delayed tPA-induced HT in stroke models, the long-term efficacy of these drugs are not yet established. Further optimization is required to expedite their future clinical application. The findings from this review indicate the need to explore the most ideal adjunctive interventions that will not only reduce delayed tPA–induced HT, but also preserve neurovascular functions. While waiting for the next breakthrough drug in acute stroke treatment, it is equally important to allocate considerable effort to find approaches to address the limitations of the only FDA-approved stroke therapy.
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Affiliation(s)
- Ike Dela Peña
- Department of Pharmaceutical and Administrative Sciences, Loma Linda University School of Pharmacy, Loma Linda, United States
| | - Cesar Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, United States
| | - Guofang Shen
- Department of Pharmaceutical and Administrative Sciences, Loma Linda University School of Pharmacy, Loma Linda, United States
| | - Willie Davis
- Department of Pharmaceutical and Administrative Sciences, Loma Linda University School of Pharmacy, Loma Linda, United States
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12
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Peña ID, Borlongan CV. Translating G-CSF as an Adjunct Therapy to Stem Cell Transplantation for Stroke. Transl Stroke Res 2016; 6:421-9. [PMID: 26482176 DOI: 10.1007/s12975-015-0430-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/05/2015] [Accepted: 10/08/2015] [Indexed: 01/26/2023]
Abstract
Among recently investigated stroke therapies, stem cell treatment holds great promise by virtue of their putative ability to replace lost cells, promote endogenous neurogenesis,and produce behavioral and functional improvement through their "bystander effects." Translating stem cell in the clinic, however, presents a number of technical difficulties. A strategy suggested to enhance therapeutic utility of stem cells is combination therapy, i.e., co-transplantation of stem cells or adjunct treatment with pharmacological agents and substrates,which is assumed to produce more profound therapeutic benefits by circumventing limitations of individual treatments and facilitating complementary brain repair processes. We previously demonstrated enhanced functional effects of cotreatment with granulocyte-colony stimulating factor (GCSF)and human umbilical cord blood cell (hUCB) transplantation in animal models of traumatic brain injury (TBI). Here,we suggest that the aforementioned combination therapy may also produce synergistic effects in stroke. Accordingly, G-CSF treatment may reduce expression of pro-inflammatory cytokines and enhance neurogenesis rendering a receptive microenvironment for hUCB engraftment. Adjunct treatment of GCSF with hUCB may facilitate stemness maintenance and guide neural lineage commitment of hUCB cells. Moreover, regenerative mechanisms afforded by G-CSF-mobilized endogenous stem cells, secretion of growth factors by hUCB grafts and G-CSF-recruited endothelial progenitor cells(EPCs), as well as the potential graft–host integration that may promote synaptic circuitry re-establishment could altogether produce more pronounced functional improvement in stroked rats subjected to a combination G-CSF treatment and hUCB transplantation. Nevertheless, differences in pathology and repair processes underlying TBI and stroke deserve consideration when testing the effects of combinatorial G-CSF and hUCB cell transplantation for stroke treatment. Further studies are also required to determine the safety and efficacy of this intervention in both preclinical and clinical stroke studies.
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Thrombolytic therapy with rt-PA and transcranial color Doppler ultrasound (TCCS) combined with microbubbles for embolic thrombus. Thromb Res 2015; 136:1027-32. [DOI: 10.1016/j.thromres.2015.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/29/2015] [Accepted: 08/29/2015] [Indexed: 11/22/2022]
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Nelson PT, Jicha GA. Cerebrospinal fluid vascular endothelial growth factor. JAMA Neurol 2015; 72:502-3. [PMID: 25751033 DOI: 10.1001/jamaneurol.2015.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Peter T Nelson
- Sanders-Brown Center on Aging, Division of Neuropathology, Department of Pathology, University of Kentucky, Lexington
| | - Gregory A Jicha
- Sanders-Brown Center on Aging, Division of Neuropathology, Department of Pathology, University of Kentucky, Lexington
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Hemorrhagic transformation after ischemic stroke in animals and humans. J Cereb Blood Flow Metab 2014; 34:185-99. [PMID: 24281743 PMCID: PMC3915212 DOI: 10.1038/jcbfm.2013.203] [Citation(s) in RCA: 379] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/10/2013] [Accepted: 10/28/2013] [Indexed: 01/12/2023]
Abstract
Hemorrhagic transformation (HT) is a common complication of ischemic stroke that is exacerbated by thrombolytic therapy. Methods to better prevent, predict, and treat HT are needed. In this review, we summarize studies of HT in both animals and humans. We propose that early HT (<18 to 24 hours after stroke onset) relates to leukocyte-derived matrix metalloproteinase-9 (MMP-9) and brain-derived MMP-2 that damage the neurovascular unit and promote blood-brain barrier (BBB) disruption. This contrasts to delayed HT (>18 to 24 hours after stroke) that relates to ischemia activation of brain proteases (MMP-2, MMP-3, MMP-9, and endogenous tissue plasminogen activator), neuroinflammation, and factors that promote vascular remodeling (vascular endothelial growth factor and high-moblity-group-box-1). Processes that mediate BBB repair and reduce HT risk are discussed, including transforming growth factor beta signaling in monocytes, Src kinase signaling, MMP inhibitors, and inhibitors of reactive oxygen species. Finally, clinical features associated with HT in patients with stroke are reviewed, including approaches to predict HT by clinical factors, brain imaging, and blood biomarkers. Though remarkable advances in our understanding of HT have been made, additional efforts are needed to translate these discoveries to the clinic and reduce the impact of HT on patients with ischemic stroke.
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Rodríguez JA, Sobrino T, Orbe J, Purroy A, Martínez-Vila E, Castillo J, Páramo JA. proMetalloproteinase-10 is associated with brain damage and clinical outcome in acute ischemic stroke. J Thromb Haemost 2013; 11:1464-73. [PMID: 23742289 DOI: 10.1111/jth.12312] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND Matrix metalloproteinases (MMPs) mediate tissue injury during stroke but also neurovascular remodeling and we have shown that MMP-10 is involved in atherothrombosis. OBJECTIVE The purpose of this study was to examine the relationship between proMMP-10 and clinical outcome, assessing inflammatory and proteolytic markers, in patients with acute ischemic stroke. METHODS We prospectively studied 76 patients with ischemic stroke treated with tPA within the first 3 h from symptom onset, compared with 202 non-tPA-treated ischemic stroke patients and 83 asymptomatic subjects. Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS). Hemorrhagic transformation (HT) and severe brain edema were diagnosed by cranial CT. Good functional outcome was defined as a modified Rankin scale score ≤ 2 at 90 days. Serum levels of MMP-9, proMMP-10, TIMP-1, tumor necrosis factor-α (TNFα), interleukin-6 and cellular fibronectin were measured at admission. The effect of TNFα on endothelial proMMP-10 was assessed in vitro. RESULTS Serum proMMP-10 concentration in ischemic stroke patients, non-treated or treated with t-PA, which was higher than age-matched healthy subjects (P < 0.0001), was independently associated with higher infarct volume, severe brain edema, neurological deterioration and poor functional outcome at 3 months (all P < 0.05), but not with HT. proMMP-10 levels were also independently and positively associated with circulating levels of TNFα (P < 0.0001), which induced its endothelial expression in vitro, both mRNA and protein. MMP-9, however, was only associated with HT and severe edema (all P < 0.05). CONCLUSIONS Increased serum proMMP-10 after acute ischemic stroke, associated with TNFα, is a new marker of brain damage and poor outcome.
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Affiliation(s)
- J A Rodríguez
- Laboratory of Atherosclerosis, Division of Cardiovascular Sciences, CIMA-University of Navarra, Pamplona, Spain.
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Rodríguez-González R, Blanco M, Rodríguez-Yáñez M, Moldes O, Castillo J, Sobrino T. Platelet derived growth factor-CC isoform is associated with hemorrhagic transformation in ischemic stroke patients treated with tissue plasminogen activator. Atherosclerosis 2012; 226:165-71. [PMID: 23218119 DOI: 10.1016/j.atherosclerosis.2012.10.072] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 10/15/2012] [Accepted: 10/30/2012] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Platelet derived growth factor-CC (PDGF-CC) isoform is activated by tissue plasminogen activator (tPA) regulating blood brain barrier permeability after ischemia. We aimed to study the association of PDGF isoforms serum levels with hemorrhagic transformation (HT) and edema after thrombolytic treatment in ischemic stroke. METHODS We studied 129 patients with ischemic stroke treated with tPA within the first 4.5 h (h) from stroke onset. CT was performed on admission and at 24-36 h. On the 2nd CT, HT was classified according to ECASS II criteria, and severe brain edema was diagnosed if extensive swelling causing any shifting of the structures of the midline was detected. PDGF-AA, PDGF-AB, PDGF-BB and PDGF-CC serum levels were analyzed by ELISA on admission (before tPA bolus), at 24 and 72 h. RESULTS Patients who developed HT showed only higher levels of PDGF-CC isoform on admission and at 24 h (all p < 0.0001). In the multivariate analysis, PDGF-CC levels on admission (OR, 1.02; CI 95%, 1.00-1.04) and at 24 h (OR, 1.05; CI 95%, 1.02-1.08) were independently associated with HT after adjustment by confounding factors. On the other hand, patients with severe edema showed also higher levels of PDGF-CC on admission and at 24 h (p < 0.0001), but this statistical association was lost in the logistic regression analysis. PDGF-CC levels ≥ 175 ng/mL at 24 h predict the development of PH with a sensitivity of 90% and specificity of 88% (area under the curve 0.936; p < 0.0001). CONCLUSION Increased PDGF-CC levels after tPA treatment is associated with HT.
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Affiliation(s)
- Raquel Rodríguez-González
- Clinical Neurosciences Research Laboratory, Neurovascular Area, Department of Neurology, Hospital Clínico Universitario, IDIS, University of Santiago de Compostela, Santiago de Compostela, Spain
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Navarro-Sobrino M, Rosell A, Hernández-Guillamon M, Penalba A, Boada C, Domingues-Montanari S, Ribó M, Alvarez-Sabín J, Montaner J. A large screening of angiogenesis biomarkers and their association with neurological outcome after ischemic stroke. Atherosclerosis 2011; 216:205-11. [PMID: 21324462 DOI: 10.1016/j.atherosclerosis.2011.01.030] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 01/13/2011] [Accepted: 01/18/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND The induction of angiogenesis after stroke may enhance neurorestorative processes. Our aim was to examine the endogenous angiogenesis balance and their association with long-term clinical outcome in ischemic stroke patients. METHODS A total of 109 stroke subjects were included in the study. Firstly, plasma samples were obtained from control subjects (n = 26) and tPA-treated stroke patients (n = 29) at baseline (within 3h of symptoms onset), 1, 2, 12, 24h after tPA treatment, at discharge and 3 months after the ischemic event. Angiogenic promoters (PDGF-AA, PDGF-BB, HGF, FGF, KGF, HB-EGF, TPO, VEGF, VEGFR-1, VEGFR-2 and SDF-1α) and inhibitors (endostatin, angiostatin, thrombospondin-1 and thrombospondin-2) were analyzed by Searchlight(®) technology or ELISA. Additionally, baseline and 24h endostatin plasma level was determined in a new set of stroke patients (n = 80). Clinical parameters (NIHSS, mRS, mortality and hemorrhagic transformation events) were assessed to evaluate outcome. RESULTS Baseline PDGF-BB, endostatin and thrombospondin-2 levels were higher in stroke patients than in controls (p < 0.05). A pro-angiogenic balance was associated with lower NIHSS scores and less intracranial hemorrhagic complications. Interestingly, a high baseline endostatin level was associated to long-term functional dependency (mRS > 2; p = 0.004). Finally, a baseline endostatin cut-off point of 184 ng/mL was an independent predictor of functional dependency at three months in the multiple logistic regression with an odds ratio of 8.9 (95% CI: 2.7-28.8; p = 0.0002). CONCLUSIONS Our results indicate that an early pro-angiogenic balance is associated with mild short-term neurological deficit, while an acute anti-angiogenesis status determined by high endostatin plasma level predicts a worse long-term functional outcome.
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Affiliation(s)
- Míriam Navarro-Sobrino
- Neurovascular Research Laboratory and Neurovascular Unit, Neurology and Medicine Department-Universitat Autònoma de Barcelona, Research Institute of the Vall d'Hebron Hospital, Barcelona, Spain
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