The failure of neuronal protective agents versus the success of thrombolysis in the treatment of ischemic stroke. The predictive value of animal models

Preclinical animal studies in ischemic stroke: Challenges and some solutions

Despite the impressive efficacies demonstrated in preclinical research, hundreds of potentially neuroprotective drugs have failed to provide effective neuroprotection for ischemic stroke in human clinical trials. Lack of a powerful animal model for human ischemic stroke could be a major reason for the failure to develop successful neuroprotective drugs for ischemic stroke. This review recapitulates the available cerebral ischemia animal models, provides an anatomical comparison of the circle of Willis of each species, and describes the functional assessment tests used in these ischemic stroke models. The distinct differences between human ischemic stroke and experimental stroke in available animal models is explored. Innovative animal models more closely resembling human strokes, better techniques in functional outcome assessment and better experimental designs generating clearer and stronger evidence may help realise the development of truly neuroprotective drugs that will benefit human ischemic stroke patients. This may involve use of newer molecules or revisiting earlier studies with new experimental designs. Translation of any resultant successes may then be tested in human clinical trials with greater confidence and optimism.

Selecting Patients for Intra-Arterial Therapy in the Context of a Clinical Trial for Neuroprotection

BACKGROUND AND PURPOSE

The advent of intra-arterial neurothrombectomy (IAT) for acute ischemic stroke opens a potentially transformative opportunity to improve neuroprotection studies. Combining a putative neuroprotectant with recanalization could produce more powerful trials but could introduce heterogeneity and adverse event possibilities. We sought to demonstrate feasibility of IAT in neuroprotectant trials by defining IAT selection criteria for an ongoing neuroprotectant clinical trial.

METHODS

The study drug, 3K3A-APC, is a pleiotropic cytoprotectant and may reduce thrombolysis-associated hemorrhage. The NeuroNEXT trial NN104 (RHAPSODY) is designed to establish a maximally tolerated dose of 3K3A-APC. Each trial site provided their IAT selection criteria. An expert panel reviewed site criteria and published evidence. Finally, the trial leadership designed IAT selection criteria.

RESULTS

Derived selection criteria reflected consistency among the sites and comparability to published IAT trials. A protocol amendment allowing IAT (and relaxed age, National Institutes of Health Stroke Scale, and time limits) in the RHAPSODY trial was implemented on June 15, 2015. Recruitment before and after the amendment improved from 8 enrolled patients (601 screened, 1.3%) to 51 patients (821 screened, 6.2%; odds ratio [95% confidence limit] of 4.9 [2.3-10.4]; P<0.001). Gross recruitment was 0.11 patients per site month versus 0.43 patients per site per month, respectively, before and after the amendment.

CONCLUSIONS

It is feasible to include IAT in a neuroprotectant trial for acute ischemic stroke. Criteria are presented for including such patients in a manner that is consistent with published evidence for IAT while still preserving the ability to test the role of the putative neuroprotectant.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02222714.

Neuroprotective actions of taurine on hypoxic-ischemic brain damage in neonatal rats

Taurine is an abundant amino acid in the nervous system, which has been proved to possess antioxidation, osmoregulation and membrane stabilization. Previously it has been demonstrated that taurine exerts ischemic brain injury protective effect. This study was designed to investigate whether the protective effect of taurine has the possibility to be applied to treat neonatal hypoxic-ischemic brain damage. Seven-day-old Sprague-Dawley rats were treated with left carotid artery ligation followed by exposure to 8% oxygen to generate the experimental group. The cerebral damage area was measured after taurine post-treatment with 2,3,5-triphenyltetrazolium chloride (TTC) staining, Hematoxyline-Eosin (HE) staining and Nissl staining. The activities of superoxide dismutase (SOD), malondialdehyde (MDA), glutathione peroxidase (GSH-Px), total antioxidant capacity (T-AOC), myeloperoxtidase (MPO), ATP and Lactic Acid productions were assayed with ipsilateral hemisphere homogenates. Western-blot and immunofluorescence assay were processed to detect the expressions of AIF, Cyt C, Bax, Bcl-2 in brain. We found that taurine significantly reduced brain infarct volume and ameliorated morphological injury obviously reversed the changes of SOD, MDA, GSH-Px, T-AOC, ATP, MPO, and Lactic Acid levels. Compared with hypoxic-ischemic group, it showed marked reduction of AIF, Cyt C and Bax expressions and increase of Bcl-2 after post-treatment. We conclude that taurine possesses an efficacious neuroprotective effect after cerebral hypoxic-ischemic damage in neonatal rats.

Animal models and conserved processes

BACKGROUND

The concept of conserved processes presents unique opportunities for using nonhuman animal models in biomedical research. However, the concept must be examined in the context that humans and nonhuman animals are evolved, complex, adaptive systems. Given that nonhuman animals are examples of living systems that are differently complex from humans, what does the existence of a conserved gene or process imply for inter-species extrapolation?

METHODS

We surveyed the literature including philosophy of science, biological complexity, conserved processes, evolutionary biology, comparative medicine, anti-neoplastic agents, inhalational anesthetics, and drug development journals in order to determine the value of nonhuman animal models when studying conserved processes.

RESULTS

Evolution through natural selection has employed components and processes both to produce the same outcomes among species but also to generate different functions and traits. Many genes and processes are conserved, but new combinations of these processes or different regulation of the genes involved in these processes have resulted in unique organisms. Further, there is a hierarchy of organization in complex living systems. At some levels, the components are simple systems that can be analyzed by mathematics or the physical sciences, while at other levels the system cannot be fully analyzed by reducing it to a physical system. The study of complex living systems must alternate between focusing on the parts and examining the intact whole organism while taking into account the connections between the two. Systems biology aims for this holism. We examined the actions of inhalational anesthetic agents and anti-neoplastic agents in order to address what the characteristics of complex living systems imply for inter-species extrapolation of traits and responses related to conserved processes.

CONCLUSION

We conclude that even the presence of conserved processes is insufficient for inter-species extrapolation when the trait or response being studied is located at higher levels of organization, is in a different module, or is influenced by other modules. However, when the examination of the conserved process occurs at the same level of organization or in the same module, and hence is subject to study solely by reductionism, then extrapolation is possible.

WebParc: a tool for analysis of the topography and volume of stroke from MRI

The quantitative assessment of the anatomic consequences of cerebral infarction is critical in the study of the etiology and therapeutic response in patients with stroke. We present here an overview of the operation of "WebParc," a computational system that provides measures of stroke lesion volume and location with respect to canonical forebrain neural systems nomenclature. Using a web-based interface, clinical imaging data can be registered to a template brain that contains a comprehensive set of anatomic structures. Upon delineation of the lesion, we can express the size and localization of the lesion in terms of the regions that are intersected within the template. We demonstrate the application of the system using MRI-based diffusion-weighted imaging and document measures of the validity and reliability of its uses. Intra- and inter-rater reliability is demonstrated, and characterized relative to the various classes of anatomic regions that can be assessed. The WebParc system has been developed to meet criteria of both efficiency and intuitive operator use in the real time analysis of stroke anatomy, so as to be useful in support of clinical care and clinical research studies. This article is an overview of its base-line operation with quantitative anatomic characterization of lesion size and location in terms of stroke distribution within the separate gray and white matter compartments of the brain.

Translating promising preclinical neuroprotective therapies to human stroke trials

Stroke is the third leading cause of mortality and carries the greatest socioeconomic burden of disease in North America. Despite several promising therapies discovered in the preclinical setting, there have been no positive results in human stroke clinical trials to date. In this article, we review the potential causes for failure and discuss strategies that have been proposed to overcome the barrier to translation of stroke therapies. To improve the chance of success in future human stroke trials, we propose that therapies be tested in stroke models that closely resemble the human condition with molecular, imaging and functional outcomes that relate to outcomes utilized in clinical trials. These strategies include higher-order, old-world, nonhuman primate models of stroke with clinically relevant outcome measures. Although stroke neuroprotection has been looked upon pessimistically given the many failures in clinical trials to date, we propose that neuroprotection in humans is feasible and will be realized with rigorous translational science.

Neuroprotective effect of L-serine against temporary cerebral ischemia in rats

To investigate the neuroprotective effect of L-serine and its underlying mechanisms, focal cerebral ischemia was induced in rats by occlusion of middle cerebral artery (MCAO) with a suture, and reperfusion was given by filament withdrawal 2 hr later. Meanwhile, rat hippocampal neurons were primarily cultured, and incubated in serum-free medium in an incubator containing 1% O(2) for hypoxic exposure of 5 hr, or incubated in serum-free medium containing 1 mM glutamate for glutamate exposure of 2 hr. Brain tissue injury and cell damage were then measured. L-serine dose-dependently decreased the neurology deficit score and infarct volume, elevated the cell viability and inhibited the leakage of lactate dehydrogenase. These effects were blocked by strychnine in both MCAO rats and cultured hippocampal neurons. Furthermore, L-serine (168 mg.kg(-1)) reduced the brain water content, permeability of blood-brain barrier, neuronal loss and the expression of activated caspase-3 in the cortex. In addition, L-serine effectively protected the brain from damage when it was administered within 6 hr after the end of MCAO. It is suggested that L-serine could exert a neuroprotective effect on the ischemic-reperfused brain and on the hypoxia- or glutamate-exposed hippocampal neurons, which may be mediated by activating glycine receptors.

Preservation of GABAA receptor function by PTEN inhibition protects against neuronal death in ischemic stroke

BACKGROUND AND PURPOSE

Downregulation of the tumor suppressor, phosphatase and tensin homolog deleted on chromosome 10 (PTEN), is thought to be a novel neuroprotective strategy in ischemic stroke, but the underlying mechanisms remain unclear. In this study, we aimed to validate the use of PTEN regulation of gamma-aminobutyric acid subtype A receptors (GABA(A)Rs) as a molecular target for the treatment of ischemic stroke. Because suppression of GABA(A)Rs contributes to ischemic neuron death, describing the intracellular signaling that interacts with GABA(A)Rs in ischemic neurons would provide a molecular basis for novel stroke therapies.

METHODS

We measured surface GABA(A)R expression by immunocytochemical labeling and surface protein biotinylation assay. Knockdown and overexpression approaches were used to test the effects of PTEN on the expression and function of GABA(A)Rs. Neuronal death was detected in both in vitro and in vivo stroke models.

RESULTS

The knockdown and overexpression approaches provided the first evidence that PTEN negatively regulated membrane expression and function of GABA(A)Rs in rat hippocampal neurons. Importantly, we demonstrated that a PTEN inhibitor prevented the reduction of surface GABA(A)Rs in injured hippocampal neurons subjected to oxygen-glucose deprivation, an in vitro insult that mimics ischemic injury, whereas a GABA(A)R antagonist significantly reduced this PTEN inhibitor-induced neuroprotection in both the in vitro and in vivo ischemic stroke models.

CONCLUSIONS

Our study provides direct evidence that downregulation of PTEN protects against ischemic neuron death by preserving GABA(A)R function. Targeting this pathway may be an effective strategy for development of selective, potent stroke treatments.

Rodent models of focal cerebral ischemia: procedural pitfalls and translational problems

Rodent models of focal cerebral ischemia are essential tools in experimental stroke research. They have added tremendously to our understanding of injury mechanisms in stroke and have helped to identify potential therapeutic targets. A plethora of substances, however, in particular an overwhelming number of putative neuroprotective agents, have been shown to be effective in preclinical stroke research, but have failed in clinical trials. A lot of factors may have contributed to this failure of translation from bench to bedside. Often, deficits in the quality of experimental stroke research seem to be involved. In this article, we review the commonest rodent models of focal cerebral ischemia - middle cerebral artery occlusion, photothrombosis, and embolic stroke models - with their respective advantages and problems, and we address the issue of quality in preclinical stroke modeling as well as potential reasons for translational failure.

Ginsenoside Rg1 protects neurons from hypoxic-ischemic injury possibly by inhibiting Ca2+ influx through NMDA receptors and L-type voltage-dependent Ca2+ channels

The purpose of this study is to assess the neuroprotective effect of Rg1, a ginsenoside. We measured cell viability and lactate dehydrogenase (LDH) release from primary culture of rat hippocampal neurons and electrical activities in hippocampal slices of rats, before and after the neurons were deprived of oxygen and glucose. In addition, cerebral damage was evaluated with magnetic resonance imaging after middle cerebral artery was occluded transiently. Nissl staining was used for histological observation and immunohistochemistry analysis for activated caspase-3 expression of the brain. Furthermore, calcium influx was measured with laser confocal microscopy in neurons perfused with KCl (50 mM) or N-methyl-d-aspartate (NMDA, 1 mM), or deprived of oxygen and glucose. The influences of ginsenoside Rg1 on these parameters were determined simultaneously. We found that treatment of Rg1: 1) increased the neuronal viability; 2) promoted the recovery of electrical activity in hippocampal slices; 3) reduced the release of LDH, cerebral damage area, neuronal loss and expression of caspase-3; and 4) inhibited calcium influx induced by NMDA, KCl or oxygen/glucose deprivation. However, the protective effect of Rg1 was blocked by mifepristone, an antagonist of glucocorticoid receptors. Taken together, these results suggest that ginsenoside Rg1 can reduce neuronal death, including apoptotic cell death, induced by hypoxic-ischemic insults. This neuroprotective effect is probably mediated by the activation of glucocorticoid receptors, and by the inhibition of calcium influx through NMDA receptors and L-type voltage-dependent Ca2+ channels and the resultant reduction of intracellular free Ca2+.

Systematic Reviews of Animal Experiments Demonstrate Poor Human Clinical and Toxicological Utility

The assumption that animal models are reasonably predictive of human outcomes provides the basis for their widespread use in toxicity testing and in biomedical research aimed at developing cures for human diseases. To investigate the validity of this assumption, the comprehensive Scopus biomedical bibliographic databases were searched for published systematic reviews of the human clinical or toxicological utility of animal experiments. In 20 reviews in which clinical utility was examined, the authors concluded that animal models were either significantly useful in contributing to the development of clinical interventions, or were substantially consistent with clinical outcomes, in only two cases, one of which was contentious. These included reviews of the clinical utility of experiments expected by ethics committees to lead to medical advances, of highly-cited experiments published in major journals, and of chimpanzee experiments — those involving the species considered most likely to be predictive of human outcomes. Seven additional reviews failed to clearly demonstrate utility in predicting human toxicological outcomes, such as carcinogenicity and teratogenicity. Consequently, animal data may not generally be assumed to be substantially useful for these purposes. Possible causes include interspecies differences, the distortion of outcomes arising from experimental environments and protocols, and the poor methodological quality of many animal experiments, which was evident in at least 11 reviews. No reviews existed in which the majority of animal experiments were of good methodological quality. Whilst the effects of some of these problems might be minimised with concerted effort (given their widespread prevalence), the limitations resulting from interspecies differences are likely to be technically and theoretically impossible to overcome. Non-animal models are generally required to pass formal scientific validation prior to their regulatory acceptance. In contrast, animal models are simply assumed to be predictive of human outcomes. These results demonstrate the invalidity of such assumptions. The consistent application of formal validation studies to all test models is clearly warranted, regardless of their animal, non-animal, historical, contemporary or possible future status. Likely benefits would include, the greater selection of models truly predictive of human outcomes, increased safety of people exposed to chemicals that have passed toxicity tests, increased efficiency during the development of human pharmaceuticals and other therapeutic interventions, and decreased wastage of animal, personnel and financial resources. The poor human clinical and toxicological utility of most animal models for which data exists, in conjunction with their generally substantial animal welfare and economic costs, justify a ban on animal models lacking scientific data clearly establishing their human predictivity or utility.

The poor contribution of chimpanzee experiments to biomedical progress

Biomedical research on captive chimpanzees incurs substantial nonhuman animal welfare, ethical, and financial costs that advocates claim resultin substantial advancements in biomedical knowledge. However, demonstrating minimal contribution toward the advancement of biomedical knowledge generally, subsequent papers did not cite 49.5% (47/95), of 95 experiments randomly selected from a population of 749 published worldwide between 1995 and 2004. Only 14.7% (14/95) were cited by 27 papers that abstracts indicated described well-developed methods for combating human diseases. However, detailed examination of these medical papers revealed that in vitrostudies, human clinical and epidemiological studies, molecular assays and methods, and genomic studies contributed most to their development. No chimpanzee study made an essential contribution, or, in most cases, a significant contribution of any kind, to the development of the medical method described. The approval of these experiments indicates a failure of the ethics committee system. The demonstrable lack of benefit of most chimpanzee experimentation and its profound animal welfare and bioethical costs indicate that a ban is warranted in those remaining countries - notably the United States - that continue to conduct it.

Neuroprotective effect of taurine against focal cerebral ischemia in rats possibly mediated by activation of both GABAA and glycine receptors

To investigate the neuroprotective effect of taurine and the involved mechanisms, middle cerebral artery occlusion (MCAO) was induced with suture for 2h in rat, and the brain tissue was then reperfused. The infarct volume and cerebral damage area were measured, respectively, with 2,3,5-triphenyltetrazolium chloride (TTC) staining and MRI. Nissl staining was used for histological observation, and immunohistochemistry and Western-blot analysis for detecting the activated caspase-3 expression. Both pre- (200mgkg(-1)) and post-treatment of taurine decreased the neurology deficit score, infarct volume and brain water content. Taurine post-treatment (67, 200 and 600mgkg(-1)) showed a dose-dependent neuroprotective effect. Taurine (200mgkg(-1)) significantly decreased neuronal loss in the cerebral cortex and hippocampus, and reduced the expression of caspase-3 as well. The neuroprotective effect of taurine was partly blunted by strychnine or bicuculline alone, and almost completely blocked by coapplication of both antagonists of glycine and GABA(A) receptors. It is suggested that taurine exerts a neuroprotective role on the brain when administered before or after MCAO. Such effect is possibly mediated by the activation of both GABA(A) receptors and strychnine-sensitive glycine receptors. Moreover, inhibition of caspase-3 expression is involved in this neuroprotective effect. These results imply a potential therapeutic use of taurine for stroke.

New Goals in Ischemic Stroke Therapy: The Experimental Approach – Harmonizing Science with Practice

Undeniable advances have been made in clinical and experimental investigation into the pathophysiology, diagnosis, and treatment of cerebral ischemia. However, with the exception of intravenous thrombolysis and some neuroprotectors, such as citicoline, the majority of the drugs successfully tested in experimental studies have failed in clinical trials. Valuable lessons for the improvement of research methodology and appropriate coordination of experimental and clinical research can be learnt from the analysis of discrepancies between the laboratory and clinic, which will allow us to increase the power and cost-effectiveness of the studies. In addition, this progress has opened the way for the investigation of very promising new therapeutic strategies, such as combined pharmacological and mechanical thrombolysis, thrombolysis and neuroprotection, or the combination of various neuroprotectors, antiapoptotic therapies, and neurorestoration therapies, such as stem cell transplants.

Neuroprotection for ischemic stroke: two decades of success and failure

Alteplase (rt-PA) is the first therapy successfully developed for acute stroke therapy. The success of rt-PA spurred development of new avenues for acute stroke management. For the last two decades, a great deal of attention has been paid to neuroprotective therapies. Initial preclinical studies demonstrated numerous drugs are effective for treating acute stroke in animal models; however, subsequent clinical trials have been frustrating, and none of the agents has proven effective. The various outcomes of preclinical and clinical trials have been the subject of much discussion. In this article, we review some key neuroprotective trials and the possible reasons for their failures. By identifying the discrepancies between preclinical studies and clinical trials, we may be able to set guidelines for future effective trials.

Gene activation and protein expression following ischaemic stroke: strategies towards neuroprotection

Current understanding of the patho-physiological events that follow acute ischaemic stroke suggests that treatment regimens could be improved by manipulation of gene transcription and protein activation, especially in the penumbra region adjacent to the infarct. An immediate reduction in excitotoxicity in response to hypoxia, as well as the subsequent inflammatory response, and beneficial control of reperfusion via collateral revascularization near the ischaemic border, together with greater control over apoptotic cell death, could improve neuronal survival and ultimately patient recovery. Highly significant differences in gene activation between animal models for stroke by middle cerebral artery occlusion, and stroke in patients, may explain why current treatment strategies based on animal models of stroke often fail. We have highlighted the complexities of cellular regulation and demonstrated a requirement for detailed studies examining cell specific protective mechanisms after stroke in humans.

Tactics for Vascular Protection After Acute Ischemic Stroke

BACKGROUND

The vascular events that happen during ischemic stroke worsen outcomes in patients by causing edema, hemorrhagic transformation, and general neurologic tissue compromise. In the past 2 decades, clinical trials in patients after ischemic stroke focused on neuroprotection, but these strategies have failed in providing actual benefit. Vascular protection represents a new field to be explored in acute ischemic stroke in order to develop new approaches to therapeutic intervention.

PURPOSE

We identified tactics likely to provide vascular protection in patients with ischemic stroke. These tactics are based on knowledge of the molecular processes involved.

SUMMARY OF REVIEW

The pathologic processes due to vascular injury after an occlusion of a cerebral artery can be separated into acute (those occurring within hrs), subacute (hrs to days), and chronic (days to mo). Targets for intervention can be identified for all three stages. In the acute phase, superoxide is the predominant mediator, followed by inflammatory mediators and proteases in the subacute phase. In the chronic phase, proapoptotic gene products have been implicated. Many already-marketed therapeutic agents (statins, angiotensin modulators, erythropoietin, minocycline, and thiazolidinediones), with proven safety in patients, have been shown to have activity against some of the key targets of vascular protection.

CONCLUSION

Currently available pharmacologic agents are poised for clinical trials of vascular protection after acute ischemic stroke.

Protein kinase C delta mediates cerebral reperfusion injury in vivo

Protein kinase C (PKC) has been implicated in mediating ischemic and reperfusion damage in multiple organs. However, conflicting reports exist on the role of individual PKC isozymes in cerebral ischemic injury. Using a peptide inhibitor selective for deltaPKC, deltaV1-1, we found that deltaPKC inhibition reduced cellular injury in a rat hippocampal slice model of cerebral ischemia [oxygen-glucose deprivation (OGD)] when present both during OGD and for the first 3 hr of reperfusion. We next demonstrated peptide delivery to the brain parenchyma after in vivo delivery by detecting biotin-conjugateddeltaV1-1 and by measuring inhibition of intracellular deltaPKC translocation, an indicator of deltaPKC activity. Delivery of deltaV1-1 decreased infarct size in an in vivo rat stroke model of transient middle cerebral artery occlusion. Importantly, deltaV1-1 had no effect when delivered immediately before ischemia. However, delivery at the onset, at 1 hr, or at 6 hr of reperfusion reduced injury by 68, 47, and 58%, respectively. Previous work has implicated deltaPKC in mediating apoptotic processes. We therefore determined whether deltaPKC inhibition altered apoptotic cell death or cell survival pathways in our models. We found that deltaV1-1 reduced numbers of terminal deoxynucleotidyl transferase-mediated biotinylated UTP nick end labeling-positive cells, indicating decreased apoptosis, increased levels of phospho-Akt, a kinase involved in cell survival pathways, and inhibited BAD (Bcl-2-associated death protein) protein translocation from the cell cytosol to the membrane, indicating inhibition of proapoptotic signaling. These data support a deleterious role for deltaPKC during reperfusion and suggest that deltaV1-1 delivery, even hours after commencement of reperfusion, may provide a therapeutic advantage after cerebral ischemia.

Targets for vascular protection after acute ischemic stroke

BACKGROUND

Vascular damage caused by cerebral ischemia leads to edema, hemorrhage formation, and worsened outcomes in ischemic stroke patients. Therapeutic interventions need to be developed to provide vascular protection. The purpose of this review is to identify the pathophysiologic processes involved in vascular damage after ischemia, which may lead to strategies to provide vascular protection in ischemic stroke patients.

SUMMARY OF COMMENT

The pathologic processes caused by vascular injury after an occlusion of a cerebral artery can be separated into acute (hours), subacute (hours to days), and chronic (days to months). Targets for intervention can be identified for all 3 stages. Acutely, superoxide is the predominant mediator, followed by inflammatory mediators and proteases subacutely. In the chronic phase, proapoptotic gene products have been implicated.

CONCLUSIONS

Pharmacological agents designed to target specific pathologic and protective processes affecting the vasculature should be used in clinical trials of vascular protection after acute ischemic stroke.

Prehospital Neuroprotective Therapy for Acute Stroke

Background and Purpose— To demonstrate that paramedic initiation of intravenous magnesium sulfate (Mg) in the field in focal stroke patients is feasible, safe, and yields significant time-savings compared with in-hospital initiation of neuroprotective therapy.

Methods— We performed an open-label clinical trial. Inclusion criteria were: (1) likely stroke as identified by the Los Angeles Prehospital Stroke Screen; (2) age 45 to 95; and (3) treatment initiation within 12 hours of symptom onset. Paramedics initiated 4 g Mg loading dose in the field, followed by 16 g over 24 hours in hospital.

Results— Twenty patients were enrolled, with mean age 74 (range 44 to 92), and 50% were male. Final diagnosis was acute cerebrovascular disease in all (ischemic 80%, hemorrhagic 20%). Study agent infusion began a median of 100 minutes after symptom onset (range 24 to 703), and 70% received study agent within 2 hours of onset. The interval from paramedic arrival on scene to study agent start was: field-initiated, 26 minutes (range 15 to 64) versus in-hospital initiated (historic controls), 139 minutes (range 66 to 300; P <0.0001). Paramedics rated patient status on hospital arrival as improved 20%, worsened 5%, and unchanged 75%. Median NIHSS on hospital arrival was 11 in all patients and 16 in patients unchanged since field treatment start. Good functional outcome at 3 months (Rankin ≤ 2) occurred in 60%. No serious adverse events were associated with field therapy initiation.

Conclusions— Field initiation of Mg sulfate in acute stroke patients is feasible and safe. Prehospital trial conduct substantially reduces on-scene to needle time and permits hyperacute delivery of neuroprotective therapy.

Biomarkers of proteolytic damage following traumatic brain injury

The history of numerous failed clinical trials designed to identify therapeutic agents to assist in improving outcomes after traumatic brain injury points to the critical importance of understanding biochemical markers of injury. Such biomarkers should be readily accessible, provide information specific to the pathologic disruptions occurring in the central nervous system, and allow improved monitoring of the progression of secondary damage. Additionally, these biomarkers should may provide investigators a window on the individual patient's response to treatment, and should contribute to prediction of outcome. Most research on this topic to date has focused on neuronspecific enolase (NSE) and S-100 proteins but these have not proven to be satisfactory for a variety of reasons. A different approach is provided by the study of 2 important proteases, caspase-3 and calpain. This paper reports the current state of knowledge concerning caspase and calpain as specific markers of TBI, and discusses all-spectrin, a principal substrate for both caspase and calpain, as well as initial findings regarding neurofilament 68 protein (NF-68).

Can the time window for administration of thrombolytics in stroke be increased?

Level 1 evidence now shows that thrombolysis in cases of acute ischaemic stroke is effective if administered within 3 hours of stroke onset. This benefit has been shown to be time dependent and potentially extends beyond 3 hours, with evidence that potentially viable penumbral tissue may be present in a significant proportion of cases well beyond 3-6 hours and, in isolated cases, perhaps up to 48 hours. This exposes a "stroke recovery gap", the difference observed between the clinical response to thrombolytic therapy in a given population of patients presenting with ischaemic stroke and the potential clinical recovery if all of the penumbra were salvaged under ideal circumstances. The means of bridging this "stroke recovery gap" using thrombolysis must involve extending the therapeutic time window (i.e. the time between stroke onset and administration of thrombolytics). Approaches to do this include the use of: (i) improved patient selection with modern neuroimaging techniques, particularly magnetic resonance imaging using perfusion-weighted image/diffusion-weighted image mismatch; (ii) newer thrombolytic agents; (iii) lower doses of these agents; (iv) varied methods of administration of thrombolytic therapy including combined intravenous and intra-arterial approaches; and (v) adjunctive therapies such as neuroprotectants. Should these means of extending the time window for thrombolysis prove successful, a more widespread use of this form of acute stroke therapy will be possible.

Why have so many drugs with stellar results in laboratory stroke models failed in clinical trials? A theory based on allometric relationships

The failure, in the clinic, of at least fourteen potential neuroprotective agents expected to aid in recovery from stroke, after studies in animal models had predicted that they would be successful, is examined in relation to principles of extrapolation of data from animals to humans. Allometric scaling of glutamate data, especially duration of elevated glutamate levels in CSF and plasma, is used to support a hypothesis that treatment needs to be extended for the time that glutamate is elevated in the individual patient. According to this scenario, trials should be restricted to patients with progressing stroke and associated elevated glutamate levels, and patients without elevated glutamate might show adverse effects of drug treatment if normal levels of glutamate, which may be associated with neuroprotection, are antagonized.

Adeno-associated virus-mediated delivery of BCL-w gene improves outcome after transient focal cerebral ischemia

A recombinant adeno-associated virus (rAAV) vector was used to overexpress the anti-apoptotic Bcl-2-family protein, BCL-w, in rat brain. Three weeks after injecting the vector into cerebral cortex and striatum on one side, temporary focal ischemia was induced by occlusion of the ipsilateral middle cerebral artery for 90 min, followed by reperfusion for 24 h. BCL-w expression was increased in cerebral cortex and striatum--and in neurons, astroglia and endothelial cells--in the brains of rats that received the rAAV-BCL-w vector, compared to rats given phosphate-buffered saline or a control vector containing the gene for green fluorescent protein. Recipients of the rAAV-BCL-w vector also showed a 30% reduction in infarct size and a 33-40% improvement in neurological function, compared to the control groups. These results provide evidence for a role of BCL-w in regulating histological and functional outcome after focal cerebral ischemia.

Toward wisdom from failure: lessons from neuroprotective stroke trials and new therapeutic directions

BACKGROUND

Neuroprotective drugs for acute stroke have appeared to work in animals, only to fail when tested in humans. With the failure of so many clinical trials, the future of neuroprotective drug development is in jeopardy. Current hypotheses and methodologies must continue to be reevaluated, and new strategies need to be explored. Summary of Review- In part 1, we review key challenges and complexities in translational stroke research by focusing on the "disconnect" in the way that neuroprotective agents have traditionally been assessed in clinical trials compared with animal models. In preclinical studies, determination of neuroprotection has relied heavily on assessment of infarct volume measurements (instead of functional outcomes), short-term (instead of long-term) end points, transient (instead of permanent) ischemia models, short (instead of extended) time windows for drug administration, and protection of cerebral gray matter (instead of both gray and white matter). Clinical trials have often been limited by inappropriately long time windows, insufficient statistical power, insensitive outcome measures, inclusion of protocol violators, failure to target specific stroke subtypes, and failure to target the ischemic penumbra. In part 2, we explore new concepts in ischemic pathophysiology that should encourage us also to think beyond the hyperacute phase of ischemia and consider the design of trials that use multiagent therapy and exploit the capacity of the brain for neuroplasticity and repair.

CONCLUSIONS

By recognizing the strengths and limitations of animal models of stroke and the shortcomings of previous clinical trials, we hope to move translational research forward for the development of new therapies for the acute and subacute stages after stroke.