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Mollet IG, Viana-Soares R, Cardoso-Pires C, Soares NL, Marto JP, Mendonça M, Queiroga CSF, Carvalho AS, Sequeira CO, Teixeira-Santos L, Fernandes TP, Aloria K, Pereira SA, Matthiesen R, Viana-Baptista M, Vieira HLA. Identification of human circulating factors following remote ischemic conditioning (RIC): Potential impact on stroke. Free Radic Biol Med 2024; 224:23-38. [PMID: 39151835 DOI: 10.1016/j.freeradbiomed.2024.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 08/19/2024]
Abstract
Remote ischemic conditioning (RIC) is a procedure consisting of short cycles of ischemia applied in a limb that activates endogenous protection in distant organs, such as the brain. Despite the promising outcomes of RIC, the biochemical factors governing inter-organ communication remain largely unexplored, particularly in humans. A pilot study on 20 healthy humans was performed to identify potential circulating biochemical factors involved in RIC signalling. Blood was collected before and immediately, 4 and 22 h after the end of RIC. To characterize the responses triggered by RIC, a combination of biochemical and proteomic analysis, along with functional in vitro tests in human cells, were performed. RIC did not alter the levels of nitric oxide, bilirubin and cell-free mitochondrial DNA. In contrast, carboxyhaemoglobin levels increased following RIC at all time points and young subset, suggesting endogenous production of carbon monoxide that is a cytoprotective gasotransmitter. Additionally, the levels of glutathione and cysteinylglycine bound to proteins also increased after RIC, while glutathione catabolism decreased. Plasma proteomic analysis identified overall 828 proteins. Several steps of statistical analysis (Student's t-test, repeated measures ANOVA, with Holm corrected pairwise p-values <0.05 threshold and fold change higher or lower than 100 %) leaded to the identification of 9 proteins with altered circulating levels in response to RIC at 4h and 22h. All 9 proteins are from extracellular space or exosomes, being involved in inflammation, angiogenesis or metabolism control. In addition, RIC-conditioned plasma from young subjects protected microglial cell culture against inflammatory stimuli, indicating an anti-inflammatory effect of RIC. Nevertheless, other functional tests in neurons or endothelial cells had no effect. Overall, we present some evidence for RIC-induced anti-inflammatory and antioxidant responses in healthy human subjects, in particular in young subjects. This study is a first step towards the disclosure of signalling factors involved in RIC-mediated inter-organ communication.
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Affiliation(s)
- Inês G Mollet
- UCIBIO, Applied Molecular Biosciences Unit, Department of Chemistry, NOVA School of Science and Technology, Universidade Nova de Lisboa, Caparica, Portugal; iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, NOVA School of Science and Technology, Universidade NOVA de Lisboa, Caparica, Portugal
| | - Ricardo Viana-Soares
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal
| | - Catarina Cardoso-Pires
- UCIBIO, Applied Molecular Biosciences Unit, Department of Chemistry, NOVA School of Science and Technology, Universidade Nova de Lisboa, Caparica, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, NOVA School of Science and Technology, Universidade NOVA de Lisboa, Caparica, Portugal
| | - Nuno L Soares
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal
| | - João Pedro Marto
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal; Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal; Centro Clínico Académico de Lisboa CCAL, Lisboa, Portugal
| | - Marcelo Mendonça
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal; Champalimaud Research, Champalimaud Center for the Unknown, Lisbon, Portugal
| | - Cláudia S F Queiroga
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal
| | - Ana S Carvalho
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal
| | - Catarina O Sequeira
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal; Centro Clínico Académico de Lisboa CCAL, Lisboa, Portugal
| | - Luísa Teixeira-Santos
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal; Centro Clínico Académico de Lisboa CCAL, Lisboa, Portugal
| | - Tatiana P Fernandes
- UCIBIO, Applied Molecular Biosciences Unit, Department of Chemistry, NOVA School of Science and Technology, Universidade Nova de Lisboa, Caparica, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, NOVA School of Science and Technology, Universidade NOVA de Lisboa, Caparica, Portugal
| | - Kerman Aloria
- Proteomics Core Facility-SGIKER, University of the Basque Country UPV/EHU, Vizcaya, Spain
| | - Sofia A Pereira
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal; Centro Clínico Académico de Lisboa CCAL, Lisboa, Portugal
| | - Rune Matthiesen
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal
| | - Miguel Viana-Baptista
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal; Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal; Centro Clínico Académico de Lisboa CCAL, Lisboa, Portugal
| | - Helena L A Vieira
- UCIBIO, Applied Molecular Biosciences Unit, Department of Chemistry, NOVA School of Science and Technology, Universidade Nova de Lisboa, Caparica, Portugal; iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, NOVA School of Science and Technology, Universidade NOVA de Lisboa, Caparica, Portugal.
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Biose IJ, Oremosu J, Bhatnagar S, Bix GJ. Promising Cerebral Blood Flow Enhancers in Acute Ischemic Stroke. Transl Stroke Res 2023; 14:863-889. [PMID: 36394792 PMCID: PMC10640530 DOI: 10.1007/s12975-022-01100-w] [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: 09/28/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/18/2022]
Abstract
Ischemic stroke presents a major global economic and public health burden. Although recent advances in available endovascular therapies show improved functional outcome, a good number of stroke patients are either ineligible or do not have access to these treatments. Also, robust collateral flow during acute ischemic stroke independently predicts the success of endovascular therapies and the outcome of stroke. Hence, adjunctive therapies for cerebral blood flow (CBF) enhancement are urgently needed. A very clear overview of the pial collaterals and the role of genetics are presented in this review. We review available evidence and advancement for potential therapies aimed at improving CBF during acute ischemic stroke. We identified heme-free soluble guanylate cyclase activators; Sanguinate, remote ischemic perconditioning; Fasudil, S1P agonists; and stimulation of the sphenopalatine ganglion as promising potential CBF-enhancing therapeutics requiring further investigation. Additionally, we outline and discuss the critical steps required to advance research strategies for clinically translatable CBF-enhancing agents in the context of acute ischemic stroke models.
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Affiliation(s)
- Ifechukwude Joachim Biose
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, 131 S. Robertson, Ste 1300, Room 1349, New Orleans, LA, 70112, USA
| | - Jadesola Oremosu
- School of Medicine, Tulane University, New Orleans, LA, 70112, USA
| | - Somya Bhatnagar
- School of Medicine, Tulane University, New Orleans, LA, 70112, USA
| | - Gregory Jaye Bix
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, 131 S. Robertson, Ste 1300, Room 1349, New Orleans, LA, 70112, USA.
- Tulane Brain Institute, Tulane University, New Orleans, LA, 70112, USA.
- Department of Neurology, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, 70122, USA.
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3
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Naraiah Mukkala A, Petrut R, Goldfarb R, Leigh Beroncal E, Ho Leung C, Khan Z, Ailenberg M, Jerkic M, Andreazza AC, Rhind SG, Jeschke MG, Kapus A, Rotstein OD. Augmented Parkin-dependent mitophagy underlies the hepatoprotective effect of remote ischemic conditioning used prior to hemorrhagic shock. Mitochondrion 2023; 70:20-30. [PMID: 36906251 DOI: 10.1016/j.mito.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/04/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND AIMS Hemorrhagic shock-resuscitation (HSR) following trauma contributes to organ dysfunction by causing ischemia-reperfusion injury (IRI). We previously showed that 'remote ischemic preconditioning' (RIPC) exerted multi-organ protection from IRI. Maintenance of mitochondrial quality by clearance of dysfunctional mitochondria via mitophagy is vital in restoring organ integrity. We hypothesized that parkin-dependent mitophagy played a role in RIPC-induced hepatoprotection following HSR. METHODS The hepatoprotective effect of RIPC in a murine model of HSR-IRI was investigated in wild type and parkin-/- animals. Mice were subjected to HSR ± RIPC and blood and organs were collected, followed by cytokine ELISAs, histology, qPCR, Western blots, and transmission electron microscopy. RESULTS HSR increased hepatocellular injury, as measured by plasma ALT and liver necrosis, while antecedent RIPC prevented this injury; in parkin-/- mice, RIPC failed to exert hepatoprotection. The ability of RIPC to lessen HSR-induced rises in plasma IL-6 and TNFα, was lost in parkin-/- mice. While RIPC alone did not induce mitophagy, the application of RIPC prior to HSR caused a synergistic increase in mitophagy, this increase was not observed in parkin-/- mice. RIPC induced shifts in mitochondrial morphology favoring mitophagy in WT but not in parkin-/- animals. CONCLUSIONS RIPC was hepatoprotective in WT mice following HSR but not in parkin-/- mice. Loss of protection in parkin-/- mice corresponded with the failure of RIPC plus HSR to upregulate the mitophagic process. Improving mitochondrial quality by modulating mitophagy, may prove to be an attractive therapeutic target in disease processes caused by IRI.
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Affiliation(s)
- Avinash Naraiah Mukkala
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Raluca Petrut
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Rachel Goldfarb
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | | | - Chung Ho Leung
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Zahra Khan
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Menachem Ailenberg
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Mirjana Jerkic
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada
| | - Ana C Andreazza
- Department of Pharmacology & Toxicology, University of Toronto, Toronto, Canada
| | - Shawn G Rhind
- Defence Research and Development Canada, Department of National Defense, Government of Canada, Toronto, Canada
| | - Marc G Jeschke
- Hamilton Health Sciences Centre and McMaster University, Hamilton, Canada
| | - Andras Kapus
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada; Department of Biochemistry, University of Toronto, Toronto, Canada
| | - Ori D Rotstein
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada.
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Mollet I, Marto JP, Mendonça M, Baptista MV, Vieira HLA. Remote but not Distant: a Review on Experimental Models and Clinical Trials in Remote Ischemic Conditioning as Potential Therapy in Ischemic Stroke. Mol Neurobiol 2021; 59:294-325. [PMID: 34686988 PMCID: PMC8533672 DOI: 10.1007/s12035-021-02585-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/29/2021] [Indexed: 12/19/2022]
Abstract
Stroke is one of the main causes of neurological disability worldwide and the second cause of death in people over 65 years old, resulting in great economic and social burden. Ischemic stroke accounts for 85% of total cases, and the approved therapies are based on re-establishment of blood flow, and do not directly target brain parenchyma. Thus, novel therapies are urgently needed. In this review, limb remote ischemic conditioning (RIC) is revised and discussed as a potential therapy against ischemic stroke. The review targets both (i) fundamental research based on experimental models and (ii) clinical research based on clinical trials and human interventional studies with healthy volunteers. Moreover, it also presents two approaches concerning RIC mechanisms in stroke: (i) description of the underlying cerebral cellular and molecular mechanisms triggered by limb RIC that promote neuroprotection against stroke induced damage and (ii) the identification of signaling factors involved in inter-organ communication following RIC procedure. Limb to brain remote signaling can occur via circulating biochemical factors, immune cells, and/or stimulation of autonomic nervous system. In this review, these three hypotheses are explored in both humans and experimental models. Finally, the challenges involved in translating experimentally generated scientific knowledge to a clinical setting are also discussed.
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Affiliation(s)
- Inês Mollet
- UCIBIO, Applied Molecular Biosciences Unit, Department of Chemistry, NOVA School of Science and Technology, Universidade NOVA de Lisboa, Campus de Caparica, 2829-526, Caparica, Portugal.,CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - João Pedro Marto
- CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal.,Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Marcelo Mendonça
- CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal.,Champalimaud Research, Champalimaud Center for the Unknown, Lisbon, Portugal
| | - Miguel Viana Baptista
- CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal.,Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Helena L A Vieira
- UCIBIO, Applied Molecular Biosciences Unit, Department of Chemistry, NOVA School of Science and Technology, Universidade NOVA de Lisboa, Campus de Caparica, 2829-526, Caparica, Portugal. .,CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal. .,Associate Laboratory i4HB - Institute for Health and Bioeconomy, NOVA School of Science and Technology, NOVA University Lisbon, Caparica, Portugal.
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5
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Ma J, Ma Y, Shuaib A, Winship IR. Improved collateral flow and reduced damage after remote ischemic perconditioning during distal middle cerebral artery occlusion in aged rats. Sci Rep 2020; 10:12392. [PMID: 32709950 PMCID: PMC7381676 DOI: 10.1038/s41598-020-69122-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/07/2020] [Indexed: 02/05/2023] Open
Abstract
Circulation through cerebral collaterals can maintain tissue viability until reperfusion is achieved. However, collateral circulation is time limited, and failure of collaterals is accelerated in the aged. Remote ischemic perconditioning (RIPerC), which involves inducing a series of repetitive, transient peripheral cycles of ischemia and reperfusion at a site remote to the brain during cerebral ischemia, may be neuroprotective and can prevent collateral failure in young adult rats. Here, we demonstrate the efficacy of RIPerC to improve blood flow through collaterals in aged (16-18 months of age) Sprague Dawley rats during a distal middle cerebral artery occlusion. Laser speckle contrast imaging and two-photon laser scanning microscopy were used to directly measure flow through collateral connections to ischemic tissue. Consistent with studies in young adult rats, RIPerC enhanced collateral flow by preventing the stroke-induced narrowing of pial arterioles during ischemia. This improved flow was associated with reduced early ischemic damage in RIPerC treated aged rats relative to controls. Thus, RIPerC is an easily administered, non-invasive neuroprotective strategy that can improve penumbral blood flow via collaterals. Enhanced collateral flow supports further investigation as an adjuvant therapy to recanalization therapy and a protective treatment to maintain tissue viability prior to reperfusion.
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Affiliation(s)
- Junqiang Ma
- Neurochemical Research Unit, Department of Psychiatry, 12-127 Clinical Sciences Building, University of Alberta, Edmonton, AB, T6G 2R3, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Yonglie Ma
- Neurochemical Research Unit, Department of Psychiatry, 12-127 Clinical Sciences Building, University of Alberta, Edmonton, AB, T6G 2R3, Canada
| | - Ashfaq Shuaib
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ian R Winship
- Neurochemical Research Unit, Department of Psychiatry, 12-127 Clinical Sciences Building, University of Alberta, Edmonton, AB, T6G 2R3, Canada.
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada.
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Han C, Liu Y, Dai R, Ismail N, Su W, Li B. Ferroptosis and Its Potential Role in Human Diseases. Front Pharmacol 2020; 11:239. [PMID: 32256352 PMCID: PMC7090218 DOI: 10.3389/fphar.2020.00239] [Citation(s) in RCA: 166] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/21/2020] [Indexed: 12/26/2022] Open
Abstract
Ferroptosis is a novel regulated cell death pattern discovered when studying the mechanism of erastin-killing RAS mutant tumor cells in 2012. It is an iron-dependent programmed cell death pathway mainly caused by an increased redox imbalance but with distinct biological and morphology characteristics when compared to other known cell death patterns. Ferroptosis is associated with various diseases including acute kidney injury, cancer, and cardiovascular, neurodegenerative, and hepatic diseases. Moreover, activation or inhibition of ferroptosis using a variety of ferroptosis initiators and inhibitors can modulate disease progression in animal models. In this review, we provide a comprehensive analysis of the characteristics of ferroptosis, its initiators and inhibitors, and the potential role of its main metabolic pathways in the treatment and prevention of various diseased states. We end the review with the current knowledge gaps in this area to provide direction for future research on ferroptosis.
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Affiliation(s)
- Chu Han
- School of Chemistry and Chemical Engineering, Beijing Institute of Technology, Beijing, China
- Advanced Research Institute of Multidisciplinary Science, Beijing Institute of Technology, Beijing, China
| | - Yuanyuan Liu
- School of Chemistry and Chemical Engineering, Beijing Institute of Technology, Beijing, China
- Advanced Research Institute of Multidisciplinary Science, Beijing Institute of Technology, Beijing, China
| | - Rongji Dai
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Nafissa Ismail
- Neuroimmunology, Stress and Endocrinology (NISE) Lab, School of Psychology, Faculty of Social Science, University of Ottawa, Ottawa, ON, Canada
- Brain and Mind Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Weijun Su
- School of Medicine, Nankai University, Tianjin, China
| | - Bo Li
- School of Chemistry and Chemical Engineering, Beijing Institute of Technology, Beijing, China
- Advanced Research Institute of Multidisciplinary Science, Beijing Institute of Technology, Beijing, China
- Beijing Key Laboratory for Separation and Analysis in Biomedicine and Pharmaceuticals, School of Life Science, Beijing Institute of Technology, Beijing, China
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Li XQ, Tao L, Zhou ZH, Cui Y, Chen HS. Remote ischemic conditioning for acute moderate ischemic stroke (RICAMIS): Rationale and design. Int J Stroke 2019; 15:454-460. [PMID: 31581929 DOI: 10.1177/1747493019879651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
RATIONALE A large number of basic and clinical studies have proved that remote ischemic conditioning has neuroprotective effect. For example, remote ischemic conditioning showed a neuroprotective role in cerebral ischemia-reperfusion injury model. Recent clinical studies suggested that remote ischemic conditioning may improve neurological function and reduce the risk of recurrence in ischemic stroke patients. However, there is a lack of convincing evidence for the neuroprotective effect of remote ischemic conditioning on ischemic stroke, which deserves further study. AIM To explore the efficacy and safety of remote ischemic conditioning for acute moderate ischemic stroke. SAMPLE SIZE ESTIMATES A maximum of 1800 subjects are required to test the superiority hypothesis with 80% power according to a one-sided 0.025 level of significance, stratified by gender, age, time from onset to treatment, National Institutes of Health Stroke Scale (6-10 vs. 11-16), degree of responsible vessel stenosis, location of stenosis, and stroke etiology. METHODS AND DESIGN Remote Ischemic Conditioning for Acute Moderate Ischemic Stroke is a prospective, random, open label, blinded endpoint and multi-center study. The subjects are divided into experimental group and control group randomly. The experimental group was treated with remote ischemic conditioning twice daily with 200 mmHg pressure for 10-14 days besides guideline-based therapy. The control group was treated according to the guidelines. STUDY OUTCOME The primary efficacy endpoint is favorable functional outcome, defined as modified Rankin Scale 0-1 at 90 days post-randomization.
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Affiliation(s)
- Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Zhong-He Zhou
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
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- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
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8
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Noronha Osório D, Viana-Soares R, Marto JP, Mendonça MD, Silva HP, Quaresma C, Viana-Baptista M, Gamboa H, Vieira HLA. Autonomic nervous system response to remote ischemic conditioning: heart rate variability assessment. BMC Cardiovasc Disord 2019; 19:211. [PMID: 31500561 PMCID: PMC6734354 DOI: 10.1186/s12872-019-1181-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/12/2019] [Indexed: 11/17/2022] Open
Abstract
Background Remote ischemic conditioning (RIC) is a procedure applied in a limb for triggering endogenous protective pathways in distant organs, namely brain or heart. The underlying mechanisms of RIC are still not fully understood, and it is hypothesized they are mediated either by humoral factors, immune cells and/or the autonomic nervous system. Herein, heart rate variability (HRV) was used to evaluate the electrophysiological processes occurring in the heart during RIC and, in turn to assess the role of autonomic nervous system. Methods Healthy subjects were submitted to RIC protocol and electrocardiography (ECG) was used to evaluate HRV, by assessing the variability of time intervals between two consecutive heart beats. This is a pilot study based on the analysis of 18 ECG from healthy subjects submitted to RIC. HRV was characterized in three domains (time, frequency and non-linear features) that can be correlated with the autonomic nervous system function. Results RIC procedure increased significantly the non-linear parameter SD2, which is associated with long term HRV. This effect was observed in all subjects and in the senior (> 60 years-old) subset analysis. SD2 increase suggests an activation of both parasympathetic and sympathetic nervous system, namely via fast vagal response (parasympathetic) and the slow sympathetic response to the baroreceptors stimulation. Conclusions RIC procedure modulates both parasympathetic and sympathetic autonomic nervous system. Furthermore, this modulation is more pronounced in the senior subset of subjects. Therefore, the autonomic nervous system regulation could be one of the mechanisms for RIC therapeutic effectiveness. Electronic supplementary material The online version of this article (10.1186/s12872-019-1181-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Noronha Osório
- LIBPhys-UNL - Laboratorio de Instrumentação, Engenharia Biomédica e Física da Radiação (LIBPhys-UNL), Departamento de Física, Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa, Monte da Caparica, 2892-516, Caparica, Portugal.,PLUX - Wireless Biosignals, S.A, Lisboa, Portugal
| | - Ricardo Viana-Soares
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal
| | - João Pedro Marto
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal.,Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Marcelo D Mendonça
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal.,Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal.,Champalimaud Research, Champalimaud Centre for the Unknown, Lisboa, 7IT - Instituto de Telecomunicações, Lisboa, Portugal
| | - Hugo P Silva
- PLUX - Wireless Biosignals, S.A, Lisboa, Portugal.,EST/IPS - Escola Superior de Tecnologia do Instituto Politécnico de Setúbal, Setúbal, Portugal.,iBET - Instituto de Biologia Experimental e Tecnológica, Oeiras, Portugal
| | - Cláudia Quaresma
- LIBPhys-UNL - Laboratorio de Instrumentação, Engenharia Biomédica e Física da Radiação (LIBPhys-UNL), Departamento de Física, Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa, Monte da Caparica, 2892-516, Caparica, Portugal
| | - Miguel Viana-Baptista
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal.,Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Hugo Gamboa
- LIBPhys-UNL - Laboratorio de Instrumentação, Engenharia Biomédica e Física da Radiação (LIBPhys-UNL), Departamento de Física, Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa, Monte da Caparica, 2892-516, Caparica, Portugal.
| | - Helena L A Vieira
- CEDOC - NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisboa, Portugal.
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Zhao W, Li S, Ren C, Meng R, Jin K, Ji X. Remote ischemic conditioning for stroke: clinical data, challenges, and future directions. Ann Clin Transl Neurol 2018; 6:186-196. [PMID: 30656197 PMCID: PMC6331204 DOI: 10.1002/acn3.691] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 12/25/2022] Open
Abstract
Despite great improvement during the past several decades, the management of stroke is still far from satisfactory, which warrants alternative or adjunctive strategies. Remote ischemic conditioning (RIC), an easy‐to‐use and noninvasive therapy, can be performed in various clinical scenarios (e.g., prehospital transportation, intrahospital, and at home), and it has been widely investigated for stroke management. RIC has been demonstrated to be well tolerated in patients with acute ischemic stroke and aneurysm subarachnoid hemorrhage, and it may benefit these patients by improving clinical outcomes; in patients with intracranial atherosclerosis, long‐term repeated RIC could be safely performed and benefit patients by reducing recurrent ischemic stroke and transient ischemic attack, as well as improving cerebral perfusion status; long‐term repeated RIC may also benefit patients with cerebral small vessel disease by slowing cognitive decline and reducing volume of white matter hyperintensities on brain MRI; in patients with severe carotid atherosclerotic stenosis undergoing stenting, preprocedural RIC could reduce the odds of new brain lesions on postprocedural MRI. Previous clinical studies suggest broad future prospects of RIC in the field of cerebrovascular diseases. However, the optimal RIC protocol and the mechanisms that RIC protects the brain is not fully clear, and there is lack of sensitive and specific biomarkers of RIC, all these dilemmas prevent RIC from entering clinical practice. This review focuses on recent advances in clinical studies of RIC in stroke management, its challenges, and the potential directions of future studies.
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Affiliation(s)
- Wenbo Zhao
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Sijie Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Ran Meng
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Kunlin Jin
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China.,Center for Neuroscience Discovery Institute for Healthy Aging University of North Texas Health Science Center Fort Worth Texas
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China.,Department of Neurosurgery Xuanwu Hospital Capital Medical University Beijing China
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10
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Li Y, Liang K, Zhang L, Hu Y, Ge Y, Zhao J. Upper Limb Ischemic Postconditioning as Adjunct Therapy in Acute Stroke Patients: A Randomized Pilot. J Stroke Cerebrovasc Dis 2018; 27:3328-3335. [PMID: 30201456 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/14/2018] [Accepted: 07/22/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE This study aims to observe the clinical effect of upper limb ischemic postconditioning (LIPostC) as an adjunct to treatment with acute stroke patients, possibly due to increased cerebral perfusion. METHODS We perform a randomized blinded placebo controlled trial in nonthrombolysis patients with acute ischemic stroke, within 72hours of ictus, divided into the LIPostC group and control group. The LIPostC group is induced by 4 cycles of intermittent repeated limb ischemia: alternating 5 minutes inflation (20mm Hg above systolic blood pressure) and 5 minutes deflation performed manually using a standard upper arm blood pressure cuff in the nonparetic arm. The control group receives a sham procedure (cuff inflation to 30mm Hg). Patients underwent the intervention from the time of enrollment to Day 14. Comparison of National Institutes of Health Stroke Scale (NIHSS) score, cerebral infarction volume, relative Perfusion weighted imaging (PWI) parameters (regional relative cerebral blood flow, regional relative mean transit time; preintervention [day 0], day 14, day 90), modified Rankin Scale (mRS; the preintervention score [day 0], the curative ratio at day 90 [we define 0-1 score as close to recovery or full recovery]). RESULTS Sixty eligible patients with acute stroke (29 LIPostC and 31 control) are recruited age 65years (SD 12.22), blood pressure 156/74mm Hg (SD 14/10), and NIHSS score 5.98 (SD 3.35), mRS score 2.25 (SD .79). Only 1 in the LIPostC group is intolerant the first cycle to give up. All patients tolerate the sham procedure. Two patients experience recurrent stroke versus none in the LIPostC group. Day 90, compared with the control group, there is a significant decrease the NIHSS score, regional relative mean transit time (P < .05) and increase the curative ratio of mRS, regional relative cerebral blood flow(P < .05) in the LIPostC group, which infarct volume decreased by 31.3% (P < .05). CONCLUSIONS LIPostC after acute stroke is well tolerated and appears safe and feasible. LIPostC may improve neurological outcome, and protective mechanisms may be increased cerebral blood flow to improve cerebral perfusion. A larger trial is warranted.
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Affiliation(s)
- Yuejuan Li
- Departments of Neurology, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Keke Liang
- Departments of Neurology, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Long Zhang
- Departments of Neurology, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Yamei Hu
- Departments of Neurology, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Yunli Ge
- Departments of Neurology, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Jianhua Zhao
- Departments of Neurology, Zhengzhou University People's Hospital, Zhengzhou, China.
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11
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Nielsen A, Hansen MB, Tietze A, Mouridsen K. Prediction of Tissue Outcome and Assessment of Treatment Effect in Acute Ischemic Stroke Using Deep Learning. Stroke 2018; 49:1394-1401. [DOI: 10.1161/strokeaha.117.019740] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Treatment options for patients with acute ischemic stroke depend on the volume of salvageable tissue. This volume assessment is currently based on fixed thresholds and single imagine modalities, limiting accuracy. We wish to develop and validate a predictive model capable of automatically identifying and combining acute imaging features to accurately predict final lesion volume.
Methods—
Using acute magnetic resonance imaging, we developed and trained a deep convolutional neural network (CNN
deep
) to predict final imaging outcome. A total of 222 patients were included, of which 187 were treated with rtPA (recombinant tissue-type plasminogen activator). The performance of CNN
deep
was compared with a shallow CNN based on the perfusion-weighted imaging biomarker Tmax (CNN
Tmax
), a shallow CNN based on a combination of 9 different biomarkers (CNN
shallow
), a generalized linear model, and thresholding of the diffusion-weighted imaging biomarker apparent diffusion coefficient (ADC) at 600×10
−6
mm
2
/s (ADC
thres
). To assess whether CNN
deep
is capable of differentiating outcomes of ±intravenous rtPA, patients not receiving intravenous rtPA were included to train CNN
deep,
−rtpa
to access a treatment effect. The networks’ performances were evaluated using visual inspection, area under the receiver operating characteristic curve (AUC), and contrast.
Results—
CNN
deep
yields significantly better performance in predicting final outcome (AUC=0.88±0.12) than generalized linear model (AUC=0.78±0.12;
P
=0.005), CNN
Tmax
(AUC=0.72±0.14;
P
<0.003), and ADC
thres
(AUC=0.66±0.13;
P
<0.0001) and a substantially better performance than CNN
shallow
(AUC=0.85±0.11;
P
=0.063). Measured by contrast, CNN
deep
improves the predictions significantly, showing superiority to all other methods (
P
≤0.003). CNN
deep
also seems to be able to differentiate outcomes based on treatment strategy with the volume of final infarct being significantly different (
P
=0.048).
Conclusions—
The considerable prediction improvement accuracy over current state of the art increases the potential for automated decision support in providing recommendations for personalized treatment plans.
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Affiliation(s)
- Anne Nielsen
- From the Department of Clinical Medicine, Center of Functionally Integrative Neuroscience and MINDLAB, Aarhus University, Denmark (A.N., M.B.H., A.T., K.M.)
- Cercare Medical ApS, Aarhus, Denmark (A.N.)
| | - Mikkel Bo Hansen
- From the Department of Clinical Medicine, Center of Functionally Integrative Neuroscience and MINDLAB, Aarhus University, Denmark (A.N., M.B.H., A.T., K.M.)
| | - Anna Tietze
- From the Department of Clinical Medicine, Center of Functionally Integrative Neuroscience and MINDLAB, Aarhus University, Denmark (A.N., M.B.H., A.T., K.M.)
- Institute of Neuroradiology, Charité Universitätsmedizin, Germany (A.T.)
| | - Kim Mouridsen
- From the Department of Clinical Medicine, Center of Functionally Integrative Neuroscience and MINDLAB, Aarhus University, Denmark (A.N., M.B.H., A.T., K.M.)
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12
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Livne M, Boldsen JK, Mikkelsen IK, Fiebach JB, Sobesky J, Mouridsen K. Boosted Tree Model Reforms Multimodal Magnetic Resonance Imaging Infarct Prediction in Acute Stroke. Stroke 2018. [PMID: 29540608 DOI: 10.1161/strokeaha.117.019440] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke imaging is pivotal for diagnosis and stratification of patients with acute ischemic stroke to treatment. The potential of combining multimodal information into reliable estimates of outcome learning calls for robust machine learning techniques with high flexibility and accuracy. We applied the novel extreme gradient boosting algorithm for multimodal magnetic resonance imaging-based infarct prediction. METHODS In a retrospective analysis of 195 patients with acute ischemic stroke, fluid-attenuated inversion recovery, diffusion-weighted imaging, and 10 perfusion parameters were derived from acute magnetic resonance imaging scans. They were integrated to predict final infarct as seen on follow-up T2-fluid-attenuated inversion recovery using the extreme gradient boosting and compared with a standard generalized linear model approach using cross-validation. Submodels for recanalization and persistent occlusion were calculated and were used to identify the important imaging markers. Performance in infarct prediction was analyzed with receiver operating characteristics. Resulting areas under the curve and accuracy rates were compared using Wilcoxon signed-rank test. RESULTS The extreme gradient boosting model demonstrated significantly higher performance in infarct prediction compared with generalized linear model in both cross-validation approaches: 5-folds (P<10e-16) and leave-one-out (P<0.015). The imaging parameters time-to-peak, mean transit time, time-to-maximum, and diffusion-weighted imaging were indicated as most valuable for infarct prediction by the systematic algorithm rating. Notably, the performance improvement was higher with 5-folds cross-validation approach than leave-one-out. CONCLUSIONS We demonstrate extreme gradient boosting as a state-of-the-art method for clinically applicable multimodal magnetic resonance imaging infarct prediction in acute ischemic stroke. Our findings emphasize the role of perfusion parameters as important biomarkers for infarct prediction. The effect of cross-validation techniques on performance indicates that the intrapatient variability is expressed in nonlinear dynamics of the imaging modalities.
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Affiliation(s)
- Michelle Livne
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.).
| | - Jens K Boldsen
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
| | - Irene K Mikkelsen
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
| | - Jochen B Fiebach
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
| | - Jan Sobesky
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
| | - Kim Mouridsen
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
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13
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Remote ischemic conditioning preserves cognition and motor coordination in a mouse model of traumatic brain injury. J Trauma Acute Care Surg 2017; 83:1074-1081. [DOI: 10.1097/ta.0000000000001626] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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14
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Ma J, Ma Y, Dong B, Bandet MV, Shuaib A, Winship IR. Prevention of the collapse of pial collaterals by remote ischemic perconditioning during acute ischemic stroke. J Cereb Blood Flow Metab 2017; 37:3001-3014. [PMID: 27909265 PMCID: PMC5536804 DOI: 10.1177/0271678x16680636] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/23/2016] [Accepted: 10/30/2016] [Indexed: 02/05/2023]
Abstract
Collateral circulation is a key variable determining prognosis and response to recanalization therapy during acute ischemic stroke. Remote ischemic perconditioning (RIPerC) involves inducing peripheral ischemia (typically in the limbs) during stroke and may reduce perfusion deficits and brain damage due to cerebral ischemia. In this study, we directly investigated pial collateral flow augmentation due to RIPerC during distal middle cerebral artery occlusion (MCAo) in rats. Blood flow through pial collaterals between the anterior cerebral artery (ACA) and the MCA was assessed in male Sprague Dawley rats using in vivo laser speckle contrast imaging (LSCI) and two photon laser scanning microscopy (TPLSM) during distal MCAo. LSCI and TPLSM revealed that RIPerC augmented collateral flow into distal MCA segments. Notably, while control rats exhibited an initial dilation followed by a progressive narrowing of pial arterioles 60 to 150-min post-MCAo (constricting to 80-90% of post-MCAo peak diameter), this constriction was prevented or reversed by RIPerC (such that vessel diameters increased to 105-110% of post-MCAo, pre-RIPerC diameter). RIPerC significantly reduced early ischemic damage measured 6 h after stroke onset. Thus, prevention of collateral collapse via RIPerC is neuroprotective and may facilitate other protective or recanalization therapies by improving blood flow in penumbral tissue.
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Affiliation(s)
- Junqiang Ma
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
- The First Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Yonglie Ma
- Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Bin Dong
- Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Mischa V Bandet
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Ashfaq Shuaib
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Ian R Winship
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
- Ian R Winship, 12-127 Clinical Sciences Building, Edmonton, AB T6G 2R3, Canada.
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15
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Blauenfeldt RA, Hougaard KD, Mouridsen K, Andersen G. High Prestroke Physical Activity Is Associated with Reduced Infarct Growth in Acute Ischemic Stroke Patients Treated with Intravenous tPA and Randomized to Remote Ischemic Perconditioning. Cerebrovasc Dis 2017; 44:88-95. [PMID: 28554177 DOI: 10.1159/000477359] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/06/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND A high prestroke physical activity (PA) level is associated with reduced stroke rate, stroke mortality, better functional outcome, and possible neuroprotective abilities. The aim of the present study was to examine the possible neuroprotective effect of prestroke PA on 24-h cerebral infarct growth in a cohort of acute ischemic stroke patients treated with intravenous tPA and randomized to remote ischemic perconditioning. METHODS In this predefined subanalysis, data from a randomized clinical trial investigating the effect of remote ischemic perconditioning (RIPerC) on AIS was used. Prestroke (7 days before admission) PA was quantified using the PA Scale for the Elderly (PASE) questionnaire at baseline. Infarct growth was evaluated using MRI (acute, 24-h, and 1-month). RESULTS PASE scores were obtained from 102 of 153 (67%) patients with a median (interquartile range) age of 66 (58-73) years. A high prestroke PA level correlated significantly with reduced acute infarct growth (24 h) in the linear regression model (4th quartile prestroke PA level compared with the 1st quartile), β4th quartile = -0.82 (95% CI -1.54 to -0.10). However, the effect of prestroke PA was present mainly in patients randomized to RIPerC, β4th quartile = -1.14 (95% CI -2.04 to -0.25). In patients randomized to RIPerC, prestroke PA was a predictor of final infarct size (1-month infarct volume), β4th quartile = -1.78 (95% CI -3.15 to -0.41). CONCLUSION In AIS patients treated with RIPerC, as add-on to intravenous thrombolysis, the level of PA the week before the stroke was associated with decreased 24-h infarct growth and final infarct size. These results are highly encouraging and stress the need for further exploration of the potentially protective effects of both PA and remote ischemic conditioning.
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Affiliation(s)
- Rolf A Blauenfeldt
- Department of Neurology, Aarhus University Hospital and Center for Functionally Integrative Neuroscience, Aarhus University Hospital, Aarhus, DenmarK
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16
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17
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Meng R, Ding Y, Asmaro K, Brogan D, Meng L, Sui M, Shi J, Duan Y, Sun Z, Yu Y, Jia J, Ji X. Ischemic Conditioning Is Safe and Effective for Octo- and Nonagenarians in Stroke Prevention and Treatment. Neurotherapeutics 2015; 12:667-77. [PMID: 25956401 PMCID: PMC4489956 DOI: 10.1007/s13311-015-0358-6] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
UNLABELLED Symptomatic intracranial arterial stenosis (SIAS) is very common in octo- and nonagenarians, especially in the Chinese population, and is likely the most common cause of stroke recurrence worldwide. Clinical trials demonstrate that endovascular treatment, such as stenting, may not be suitable for octogenarians with systemic diseases. Hence, less invasive methods for the octogenarian patients are urgently needed. Our previous study (unique identifier: NCT01321749) showed that repetitive bilateral arm ischemic preconditioning (BAIPC) reduced the incidence of stroke recurrence by improving cerebral perfusion (confirmed by single photon emission computed tomography and transcranial Doppler sonography) in patients younger than 80 years of age; however, the safety and effectiveness of BAIPC on stroke prevention in octo- and nonagenarians with SIAS are still unclear. The objective of this study was to evaluate the safety and effectiveness of BAIPC in reducing stroke recurrence in octo- and nonagenarian patients with SIAS. Fifty-eight patients with SIAS were enrolled in this randomized controlled prospective study for 180 consecutive days. All patients enrolled in the study received standard medical management. Patients in the BAIPC group (n = 30) underwent 5 cycles consisting of bilateral arm ischemia followed by reperfusion for 5 min each twice daily. Those in the control group (n = 28) underwent sham-BAIPC twice daily. Blood pressure, heart rate, local skin status, plasma myoglobin, and plasma levels of thrombotic and inflammatory markers were documented in both groups before beginning the study and for the first 30 days. Finally, the incidences of stroke recurrence and magnetic resonance imaging during the 180 days of treatment were compared. Compared with the control, BAIPC had no adverse effects on blood pressure, heart rate, local skin integrity, or plasma myoglobin, and did not induce cerebral hemorrhage in the studied cohort. BAIPC reduced plasma high sensitive C-reactive protein, interleukin-6, plasminogen activator inhibitor-1, leukocyte count, and platelet aggregation rate and elevated plasma tissue plasminogen activator (all p < 0.01). In 180 days, 2 infarctions and 7 transient ischemic attacks were observed in the BAIPC group compared with 8 infarctions and 11 transient ischemic attacks in the sham BAIPC group (p < 0.05). BAIPC may safely inhibit stroke recurrence, protect against brain ischemia, and ameliorate plasma biomarkers of inflammation and coagulation in octo- and nonagenarians with SIAS. A multicenter trial is ongoing. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov, unique identifier: NCT01570231.
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Affiliation(s)
- Ran Meng
- />Neurology Department and Cerebral Vascular Diseases Research Institute (China-America Institute of Neuroscience), Xuanwu Hospital, Capital Medical University and the Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Yuchuan Ding
- />Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201 USA
| | - Karam Asmaro
- />Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201 USA
| | - David Brogan
- />Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201 USA
| | - Lu Meng
- />Department of Biochemistry and Molecular Biology, Complex Carbohydrate Research Center, University of Georgia, Athens, GA 30602 USA
| | - Meng Sui
- />USC Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90089 USA
| | - Jingfei Shi
- />Neurology Department and Cerebral Vascular Diseases Research Institute (China-America Institute of Neuroscience), Xuanwu Hospital, Capital Medical University and the Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Yunxia Duan
- />Neurology Department and Cerebral Vascular Diseases Research Institute (China-America Institute of Neuroscience), Xuanwu Hospital, Capital Medical University and the Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Zhishan Sun
- />Neurology Department and Cerebral Vascular Diseases Research Institute (China-America Institute of Neuroscience), Xuanwu Hospital, Capital Medical University and the Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Yang Yu
- />Neurology Department and Cerebral Vascular Diseases Research Institute (China-America Institute of Neuroscience), Xuanwu Hospital, Capital Medical University and the Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
- />The 9th Medical College of Peking University, 100038 Beijing, China
| | - Jianping Jia
- />Neurology Department and Cerebral Vascular Diseases Research Institute (China-America Institute of Neuroscience), Xuanwu Hospital, Capital Medical University and the Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
| | - Xunming Ji
- />Neurology Department and Cerebral Vascular Diseases Research Institute (China-America Institute of Neuroscience), Xuanwu Hospital, Capital Medical University and the Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China
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Hansen MB, Nagenthiraja K, Ribe LR, Dupont KH, Østergaard L, Mouridsen K. Automated estimation of salvageable tissue: Comparison with expert readers. J Magn Reson Imaging 2015; 43:220-8. [DOI: 10.1002/jmri.24963] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/15/2015] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mikkel B. Hansen
- Center of Functionally Integrative Neuroscience and MINDLab, Institute of Clinical Medicine, Aarhus University; Aarhus Denmark
| | - Kartheeban Nagenthiraja
- Center of Functionally Integrative Neuroscience and MINDLab, Institute of Clinical Medicine, Aarhus University; Aarhus Denmark
| | - Lars R. Ribe
- Center of Functionally Integrative Neuroscience and MINDLab, Institute of Clinical Medicine, Aarhus University; Aarhus Denmark
| | - Kristina H. Dupont
- Center of Functionally Integrative Neuroscience and MINDLab, Institute of Clinical Medicine, Aarhus University; Aarhus Denmark
- Department of Neuroradiology; Aarhus University Hospital; Aarhus Denmark
| | - Leif Østergaard
- Center of Functionally Integrative Neuroscience and MINDLab, Institute of Clinical Medicine, Aarhus University; Aarhus Denmark
- Department of Neuroradiology; Aarhus University Hospital; Aarhus Denmark
| | - Kim Mouridsen
- Center of Functionally Integrative Neuroscience and MINDLab, Institute of Clinical Medicine, Aarhus University; Aarhus Denmark
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19
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Bulluck H, Hausenloy DJ. Ischaemic conditioning: are we there yet? Heart 2015; 101:1067-77. [DOI: 10.1136/heartjnl-2014-306531] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 03/08/2015] [Indexed: 11/04/2022] Open
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20
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Pickard JMJ, Bøtker HE, Crimi G, Davidson B, Davidson SM, Dutka D, Ferdinandy P, Ganske R, Garcia-Dorado D, Giricz Z, Gourine AV, Heusch G, Kharbanda R, Kleinbongard P, MacAllister R, McIntyre C, Meybohm P, Prunier F, Redington A, Robertson NJ, Suleiman MS, Vanezis A, Walsh S, Yellon DM, Hausenloy DJ. Remote ischemic conditioning: from experimental observation to clinical application: report from the 8th Biennial Hatter Cardiovascular Institute Workshop. Basic Res Cardiol 2014; 110:453. [PMID: 25449895 PMCID: PMC4250562 DOI: 10.1007/s00395-014-0453-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 11/14/2014] [Indexed: 12/20/2022]
Abstract
In 1993, Przyklenk and colleagues made the intriguing experimental observation that ‘brief ischemia in one vascular bed also protects remote, virgin myocardium from subsequent sustained coronary artery occlusion’ and that this effect ‘…. may be mediated by factor(s) activated, produced, or transported throughout the heart during brief ischemia/reperfusion’. This seminal study laid the foundation for the discovery of ‘remote ischemic conditioning’ (RIC), a phenomenon in which the heart is protected from the detrimental effects of acute ischemia/reperfusion injury (IRI), by applying cycles of brief ischemia and reperfusion to an organ or tissue remote from the heart. The concept of RIC quickly evolved to extend beyond the heart, encompassing inter-organ protection against acute IRI. The crucial discovery that the protective RIC stimulus could be applied non-invasively, by simply inflating and deflating a blood pressure cuff placed on the upper arm to induce cycles of brief ischemia and reperfusion, has facilitated the translation of RIC into the clinical setting. Despite intensive investigation over the last 20 years, the underlying mechanisms continue to elude researchers. In the 8th Biennial Hatter Cardiovascular Institute Workshop, recent developments in the field of RIC were discussed with a focus on new insights into the underlying mechanisms, the diversity of non-cardiac protection, new clinical applications, and large outcome studies. The scientific advances made in this field of research highlight the journey that RIC has made from being an intriguing experimental observation to a clinical application with patient benefit.
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Affiliation(s)
- Jack M. J. Pickard
- The Hatter Cardiovascular Institute, University College London Hospital and Medical School, 67 Chenies Mews, London, WC1E 6HX UK
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark
| | - Gabriele Crimi
- Cardiology Department, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Sean M. Davidson
- The Hatter Cardiovascular Institute, University College London Hospital and Medical School, 67 Chenies Mews, London, WC1E 6HX UK
| | - David Dutka
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ UK
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | | | | | - Zoltan Giricz
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | | | | | | | | | | | - Christopher McIntyre
- SchulichSchool of Medicine and Dentistry, University of Western Ontario, Ontario, Canada
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Fabrice Prunier
- Cardiology Department, L’UNAM Université, University of Angers, EA3860 Cardioprotection, Remodelage et Thrombose, University Hospital, Angers, France
| | - Andrew Redington
- The Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Nicola J. Robertson
- Neonatology, Institute for Women’s Health, University College London, London, WC1E 6HX UK
| | - M. Saadeh Suleiman
- Bristol Heart Institute Faculty of Medicine and Dentistry, University of Bristol, Bristol, UK
| | - Andrew Vanezis
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Derek M. Yellon
- The Hatter Cardiovascular Institute, University College London Hospital and Medical School, 67 Chenies Mews, London, WC1E 6HX UK
| | - Derek J. Hausenloy
- The Hatter Cardiovascular Institute, University College London Hospital and Medical School, 67 Chenies Mews, London, WC1E 6HX UK
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Low dose Hsp90 inhibitor 17AAG protects neural progenitor cells from ischemia induced death. J Cell Commun Signal 2014; 8:353-62. [PMID: 25280831 DOI: 10.1007/s12079-014-0247-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/25/2014] [Indexed: 12/19/2022] Open
Abstract
Stress adaptation effect provides cell protection against ischemia induced apoptosis. Whether this mechanism prevents other types of cell death in stroke is not well studied. This is an important question for regenerative medicine to treat stroke since other types of cell death such as necrosis are also prominent in the stroke brain apart from apoptosis. We report here that treatment with 17-N-Allylamino-17-demethoxygeldanamycin (17AAG), an Hsp90 inhibitor, protected neural progenitor cells (NPCs) against oxygen glucose deprivation (OGD) induced cell death in a dose dependent fashion. Cell death assays indicated that 17AAG not only ameliorated apoptosis, but also necrosis mediated by OGD. This NPC protection was confirmed by exposing cells to oxidative stress, a major stress signal prevalent in the stroke brain. Mechanistic studies demonstrated that 17AAG activated PI3K/Akt and MAPK cell protective pathways. More interestingly, these two pathways were activated in vivo by 17AAG and 17AAG treatment reduced infarct volume in a middle cerebral artery occlusion (MCAO) stroke model. These data suggest that 17AAG protects cells against major cell death pathways and thus might be used as a pharmacological conditioning agent for regenerative medicine for stroke.
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22
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Hougaard KD, Hjort N, Zeidler D, Sørensen L, Nørgaard A, Hansen TM, von Weitzel-Mudersbach P, Simonsen CZ, Damgaard D, Gottrup H, Svendsen K, Rasmussen PV, Ribe LR, Mikkelsen IK, Nagenthiraja K, Cho TH, Redington AN, Bøtker HE, Østergaard L, Mouridsen K, Andersen G. Remote ischemic perconditioning as an adjunct therapy to thrombolysis in patients with acute ischemic stroke: a randomized trial. Stroke 2013; 45:159-67. [PMID: 24203849 DOI: 10.1161/strokeaha.113.001346] [Citation(s) in RCA: 197] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Remote ischemic preconditioning is neuroprotective in models of acute cerebral ischemia. We tested the effect of prehospital rPerC as an adjunct to treatment with intravenous alteplase in patients with acute ischemic stroke. METHODS Open-label blinded outcome proof-of-concept study of prehospital, paramedic-administered rPerC at a 1:1 ratio in consecutive patients with suspected acute stroke. After neurological examination and MRI, patients with verified stroke receiving alteplase treatment were included and received MRI at 24 hours and 1 month and clinical re-examination after 3 months. The primary end point was penumbral salvage, defined as the volume of the perfusion-diffusion mismatch not progressing to infarction after 1 month. RESULTS Four hundred forty-three patients were randomized after provisional consent, 247 received rPerC and 196 received standard treatment. Patients with a nonstroke diagnosis (n=105) were excluded from further examinations. The remaining patients had transient ischemic attack (n=58), acute ischemic stroke (n=240), or hemorrhagic stroke (n=37). Transient ischemic attack was more frequent (P=0.006), and National Institutes of Health Stroke Scale score on admission was lower (P=0.016) in the intervention group compared with controls. Penumbral salvage, final infarct size at 1 month, infarct growth between baseline and 1 month, and clinical outcome after 3 months did not differ among groups. After adjustment for baseline perfusion and diffusion lesion severity, voxelwise analysis showed that rPerC reduced tissue risk of infarction (P=0.0003). CONCLUSIONS Although the overall results were neutral, a tissue survival analysis suggests that prehospital rPerC may have immediate neuroprotective effects. Future clinical trials should take such immediate effects, and their duration, into account. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00975962.
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Affiliation(s)
- Kristina Dupont Hougaard
- From the Department of Neurology (K.D.H., N.H., P.v.W.-M., C.Z.S., D.D., H.G., K.S., P.V.R., G.A.), Department of Neuroradiology (L.S., A.N., L.Ø.), Department of Cardiology (H.E.B.), and Mobil Emergency Care Unit Aarhus (T.M.H.), Aarhus University Hospital, Aarhus, Denmark; Center of Functionally Integrative Neuroscience, Aarhus University, Aarhus, Denmark (K.D.H., N.H., D.Z., L.R.R., I.K.M., K.N., L.Ø., K.M.); Stroke Department, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, University of Lyon, Lyon, France (T.-H.C.); and Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada (A.N.R.)
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23
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Nagenthiraja K, Walcott BP, Hansen MB, Ostergaard L, Mouridsen K. Automated decision-support system for prediction of treatment responders in acute ischemic stroke. Front Neurol 2013; 4:140. [PMID: 24133479 PMCID: PMC3783931 DOI: 10.3389/fneur.2013.00140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 09/07/2013] [Indexed: 11/23/2022] Open
Abstract
MRI is widely used in the assessment of acute ischemic stroke. In particular, it identifies the mismatch between hypoperfused and the permanently damaged tissue, the PWI-DWI mismatch volume. It is used to help triage patients into active or supportive treatment pathways. COMBAT Stroke is an automated software tool for estimating the mismatch volume and ratio based on MRI. Herein, we validate the decision made by the software with actual clinical decision rendered. Furthermore, we evaluate the association between treatment decisions (both automated and actual) and outcomes. COMBAT Stroke was used to determine PWI-DWI mismatch volume and ratio in 228 patients from two European multi-center stroke databases. We performed confusion matrix analysis to summarize the agreement between the automated selection and the clinical decision. Finally, we evaluated the clinical and imaging outcomes of the patients in the four entries of the confusion matrix (true positive, true negative, false negative, and false positive). About 186 of 228 patients with acute stroke underwent thrombolytic treatment, with the remaining 42 receiving supportive treatment only. Selection based on radiographic criteria using COMBAT Stroke classified 142 patients as potential candidates for thrombolytic treatment and 86 for supportive treatment; 60% sensitivity and 29% specificity. The patients deemed eligible for thrombolytic treatment by COMBAT Stroke demonstrated significantly higher rates of compromised tissue salvage, less neurological deficit, and were more likely to experience thrombus dissolving and reestablishment of normal blood flow at 24 h follow-up compared to those who were treated without substantial PWI-DWI mismatch. These results provide evidence that COMBAT Stroke, in addition to clinical assessment, may offer an optimal framework for a fast, efficient, and standardized clinical support tool to select patients for thrombolysis in acute ischemic stroke.
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Affiliation(s)
- Kartheeban Nagenthiraja
- Center of Functionally Integrative Neuroscience and MINDLab, Aarhus University , Aarhus , Denmark ; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School , Boston, MA , USA
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