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Fisher DG, Hoch MR, Gorick CM, Huchthausen C, Breza VR, Sharifi KA, Tvrdik P, Miller GW, Price RJ. Focused Ultrasound Impels the Delivery and Penetration of Model Therapeutics into Cerebral Cavernous Malformations. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.08.27.609060. [PMID: 39253521 PMCID: PMC11383029 DOI: 10.1101/2024.08.27.609060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
BACKGROUND Cerebral cavernous malformations (CCMs) are vascular neoplasms in the brain that can cause debilitating symptoms. Current treatments pose significant risks to some patients, motivating the development of new nonsurgical options. We recently discovered that focused ultrasound-mediated blood-brain barrier opening (FUS) arrests CCM formation and growth. Here, we build on this discovery and assess the ability of FUS to deliver model therapeutics into CCMs. METHODS Quantitative T1 mapping MRI sequences were used with 1 kDa (MultiHance; MH) and 17 kDa (GadoSpin D; GDS) contrast agents to assess the FUS-mediated delivery and penetration of model small molecule drugs and biologics, respectively, into CCMs of Krit1 mutant mice. RESULTS FUS elevated the rate of MH delivery to both the lesion core (4.6-fold) and perilesional space (6.7-fold). Total MH delivery more than doubled in the lesion core and tripled in the perilesional space when FUS was applied immediately prior to MH injection. For the model biologic drug (i.e. GDS), FUS was of greater relative benefit, resulting in 21.7-fold and 3.8-fold delivery increases to the intralesional and perilesional spaces, respectively. CONCLUSIONS FUS is capable of impelling the delivery and penetration of therapeutics into the complex and disorganized CCM microenvironment. Benefits to small molecule drug delivery are more evident in the perilesional space, while benefits to biologic delivery are more evident in CCM cores. These findings, when combined with ability of FUS alone to control CCMs, highlight the potential of FUS to serve as a powerful non-invasive therapeutic platform for CCM.
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Affiliation(s)
- Delaney G Fisher
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Matthew R Hoch
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Catherine M Gorick
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | | | - Victoria R Breza
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
| | - Khadijeh A Sharifi
- Department of Neuroscience, University of Virginia, Charlottesville, VA
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | - Petr Tvrdik
- Department of Neuroscience, University of Virginia, Charlottesville, VA
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | - G Wilson Miller
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
- Department of Radiology & Medical Imaging, University of Virginia, Charlottesville, VA
| | - Richard J Price
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA
- Department of Radiology & Medical Imaging, University of Virginia, Charlottesville, VA
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Glading A. KRIT1 in vascular biology and beyond. Biosci Rep 2024; 44:BSR20231675. [PMID: 38980708 PMCID: PMC11263069 DOI: 10.1042/bsr20231675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 06/21/2024] [Accepted: 07/09/2024] [Indexed: 07/10/2024] Open
Abstract
KRIT1 is a 75 kDa scaffolding protein which regulates endothelial cell phenotype by limiting the response to inflammatory stimuli and maintaining a quiescent and stable endothelial barrier. Loss-of-function mutations in KRIT1 lead to the development of cerebral cavernous malformations (CCM), a disease marked by the formation of abnormal blood vessels which exhibit a loss of barrier function, increased endothelial proliferation, and altered gene expression. While many advances have been made in our understanding of how KRIT1, and the functionally related proteins CCM2 and PDCD10, contribute to the regulation of blood vessels and the vascular barrier, some important open questions remain. In addition, KRIT1 is widely expressed and KRIT1 and the other CCM proteins have been shown to play important roles in non-endothelial cell types and tissues, which may or may not be related to their role as pathogenic originators of CCM. In this review, we discuss some of the unsettled questions regarding the role of KRIT1 in vascular physiology and discuss recent advances that suggest this ubiquitously expressed protein may have a role beyond the endothelial cell.
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Affiliation(s)
- Angela J. Glading
- Department of Pharmacology and Physiology, University of Rochester, Rochester, NY, U.S.A
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Dulamea AO, Lupescu IC. Cerebral cavernous malformations - An overview on genetics, clinical aspects and therapeutic strategies. J Neurol Sci 2024; 461:123044. [PMID: 38749279 DOI: 10.1016/j.jns.2024.123044] [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: 10/16/2023] [Revised: 04/28/2024] [Accepted: 05/08/2024] [Indexed: 06/13/2024]
Abstract
Cerebral cavernous malformations (CCMs) are abnormally packed blood vessels lined with endothelial cells, that do not exhibit intervening tight junctions, lack muscular and elastic layers and are usually surrounded by hemosiderin and gliosis. CCMs may be sporadic or familial autosomal dominant (FCCMs) caused by loss of function mutations in CCM1 (KRIT1), CCM2 (MGC4607), and CCM3 (PDCD10) genes. In the FCCMs, patients have multiple CCMs, different family members are affected, and developmental venous anomalies are absent. CCMs may be asymptomatic or may manifest with focal neurological deficits with or without associated hemorrhage andseizures. Recent studies identify a digenic "triple-hit" mechanism involving the aquisition of three distinct genetic mutations that culminate in phosphatidylinositol-3-kinase (PIK3CA) gain of function, as the basis for rapidly growing and clinically symptomatic CCMs. The pathophysiology of CCMs involves signaling aberrations in the neurovascular unit, including proliferative dysangiogenesis, blood-brain barrier hyperpermeability, inflammation and immune mediated processes, anticoagulant vascular domain, and gut microbiome-driven mechanisms. Clinical trials are investigating potential therapies, magnetic resonance imaging and plasma biomarkers for hemorrhage and CCMs-related epilepsy, as well as different techniques of neuronavigation and neurosonology to guide surgery in order to minimize post-operatory morbidity and mortality. This review addresses the recent data about the natural history, genetics, neuroimaging and therapeutic approaches for CCMs.
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Affiliation(s)
- Adriana Octaviana Dulamea
- Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; Fundeni Clinical Institute, Department of Neurology, 258 Fundeni Street, 022328 Bucharest, Romania.
| | - Ioan Cristian Lupescu
- Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; Fundeni Clinical Institute, Department of Neurology, 258 Fundeni Street, 022328 Bucharest, Romania
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Phi JH, Kim SK. Clinical Features and Treatment of Pediatric Cerebral Cavernous Malformations. J Korean Neurosurg Soc 2024; 67:299-307. [PMID: 38547881 PMCID: PMC11079565 DOI: 10.3340/jkns.2024.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024] Open
Abstract
Cerebral cavernous malformation (CCM) is a vascular anomaly commonly found in children and young adults. Common clinical presentations of pediatric patients with CCMs include headache, focal neurological deficits, and seizures. Approximately 40% of pediatric patients are asymptomatic. Understanding the natural history of CCM is crucial and hemorrhagic rates are higher in patients with an initial hemorrhagic presentation, whereas it is low in asymptomatic patients. There is a phenomenon known as temporal clustering in which a higher frequency of symptomatic hemorrhages occurs within a few years following the initial hemorrhagic event. Surgical resection remains the mainstay of treatment for pediatric CCMs. Excision of a hemosiderin-laden rim is controversial regarding its impact on epilepsy outcomes. Stereotactic radiosurgery is an alternative treatment, especially for deepseated CCMs, but its true efficacy needs to be verified in a clinical trial.
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Affiliation(s)
- Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
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Hage S, Kinkade S, Girard R, Flemming KD, Kim H, Torbey MT, Huang J, Huston J, Shu Y, Selwyn RG, Hart BL, Mabray MC, Feghali J, Sair HI, Narvid J, Lupo JM, Lee J, Stadnik A, Alcazar-Felix RJ, Shenkar R, Hobson N, DeBiasse D, Lane K, McBee NA, Treine K, Ostapkovich N, Wang Y, Thompson RE, Koenig JI, Carroll T, Hanley DF, Awad IA. Trial Readiness of Cavernous Malformations With Symptomatic Hemorrhage, Part II: Biomarkers and Trial Modeling. Stroke 2024; 55:31-39. [PMID: 38134265 PMCID: PMC10752356 DOI: 10.1161/strokeaha.123.044083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/12/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Quantitative susceptibility mapping (QSM) and dynamic contrast-enhanced quantitative perfusion (DCEQP) magnetic resonance imaging sequences assessing iron deposition and vascular permeability were previously correlated with new hemorrhage in cerebral cavernous malformations. We assessed their prospective changes in a multisite trial-readiness project. METHODS Patients with cavernous malformation and symptomatic hemorrhage (SH) in the prior year, without prior or planned lesion resection or irradiation were enrolled. Mean QSM and DCEQP of the SH lesion were acquired at baseline and at 1- and 2-year follow-ups. Sensitivity and specificity of biomarker changes were analyzed in relation to predefined criteria for recurrent SH or asymptomatic change. Sample size calculations for hypothesized therapeutic effects were conducted. RESULTS We logged 143 QSM and 130 DCEQP paired annual assessments. Annual QSM change was greater in cases with SH than in cases without SH (P=0.019). Annual QSM increase by ≥6% occurred in 7 of 7 cases (100%) with recurrent SH and in 7 of 10 cases (70%) with asymptomatic change during the same epoch and 3.82× more frequently than clinical events. DCEQP change had lower sensitivity for SH and asymptomatic change than QSM change and greater variance. A trial with the smallest sample size would detect a 30% difference in QSM annual change during 2 years of follow-up in 34 or 42 subjects (1 and 2 tailed, respectively); power, 0.8, α=0.05. CONCLUSIONS Assessment of QSM change is feasible and sensitive to recurrent bleeding in cavernous malformations. Evaluation of an intervention on QSM percent change may be used as a time-averaged difference between 2 arms using a repeated measures analysis. DCEQP change is associated with lesser sensitivity and higher variability than QSM. These results are the basis of an application for certification by the US Food and Drug Administration of QSM as a biomarker of drug effect on bleeding in cavernous malformations. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03652181.
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Affiliation(s)
- Stephanie Hage
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Serena Kinkade
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
| | | | - Helen Kim
- Department of Anesthesiology and Perioperative Care, Center for Cerebrovascular Research (H.K.), University of California, San Francisco
| | - Michel T Torbey
- Department of Neurology (M.T.T.), University of New Mexico, Albuquerque
| | | | - John Huston
- Radiology (J. Huston, Y.S.), Mayo Clinic, Rochester, MN
| | - Yunhong Shu
- Radiology (J. Huston, Y.S.), Mayo Clinic, Rochester, MN
| | - Reed G Selwyn
- Department of Diagnostic Radiology (R.G.S., B.L.H.), University of New Mexico, Albuquerque
| | - Blaine L Hart
- Department of Diagnostic Radiology (R.G.S., B.L.H.), University of New Mexico, Albuquerque
| | - Marc C Mabray
- Department of Radiology (M.C.M.), University of New Mexico, Albuquerque
| | | | - Haris I Sair
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, MD (H.I.S.)
| | - Jared Narvid
- Department of Radiology and Biomedical Imaging (J.N., J.M.L.), University of California, San Francisco
| | - Janine M Lupo
- Department of Radiology and Biomedical Imaging (J.N., J.M.L.), University of California, San Francisco
| | - Justine Lee
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Roberto J Alcazar-Felix
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Robert Shenkar
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Nicholas Hobson
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Dorothy DeBiasse
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Karen Lane
- Brain Injury Outcomes Unit, Department of Neurology (K.L., N.A.M., K.T., N.O., Y.W., R.E.T., D.F.H.), Johns Hopkins University Medical Institutions, Baltimore, MD
| | - Nichole A McBee
- Brain Injury Outcomes Unit, Department of Neurology (K.L., N.A.M., K.T., N.O., Y.W., R.E.T., D.F.H.), Johns Hopkins University Medical Institutions, Baltimore, MD
| | - Kevin Treine
- Brain Injury Outcomes Unit, Department of Neurology (K.L., N.A.M., K.T., N.O., Y.W., R.E.T., D.F.H.), Johns Hopkins University Medical Institutions, Baltimore, MD
| | - Noeleen Ostapkovich
- Brain Injury Outcomes Unit, Department of Neurology (K.L., N.A.M., K.T., N.O., Y.W., R.E.T., D.F.H.), Johns Hopkins University Medical Institutions, Baltimore, MD
| | - Ying Wang
- Brain Injury Outcomes Unit, Department of Neurology (K.L., N.A.M., K.T., N.O., Y.W., R.E.T., D.F.H.), Johns Hopkins University Medical Institutions, Baltimore, MD
| | - Richard E Thompson
- Brain Injury Outcomes Unit, Department of Neurology (K.L., N.A.M., K.T., N.O., Y.W., R.E.T., D.F.H.), Johns Hopkins University Medical Institutions, Baltimore, MD
| | - James I Koenig
- National Institute of Neurological Disorders and Stroke, Bethesda, MD (J.K.)
| | - Timothy Carroll
- Department of Diagnostic Radiology (T.C.), University of Chicago Medicine and Biological Sciences, IL
| | - Daniel F Hanley
- Brain Injury Outcomes Unit, Department of Neurology (K.L., N.A.M., K.T., N.O., Y.W., R.E.T., D.F.H.), Johns Hopkins University Medical Institutions, Baltimore, MD
| | - Issam A Awad
- Neurovascular Surgery Program, Department of Neurological Surgery (S.H., S.K., R.G., J.L., A.S., R.J.A.-F., R.S., N.H., D.D., I.A.A.), University of Chicago Medicine and Biological Sciences, IL
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Patel A, Valle D, Nguyen A, Molina E, Lucke-Wold B. Role of Genetics and Surgical Interventions for the Management of Cerebral Cavernous Malformations (CMM). CURRENT CHINESE SCIENCE 2023; 3:386-395. [PMID: 37981909 PMCID: PMC10657140 DOI: 10.2174/2210298103666230823094431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/21/2023] [Accepted: 07/14/2023] [Indexed: 11/21/2023]
Abstract
Cerebral cavernous malformations (CCMs) are comprised of tissue matter within the brain possessing anomalous vascular architecture. In totality, the dilated appearance of the cavernomatakes on a mulberry-like shape contributed by the shape and relation to vascular and capillary elements. Analyzing its pathophysiology along with its molecular and genetic pathways plays a vital role in whether or not a patient receives GKRS, medical management, or Surgery, the most invasive of procedures. To avoid neurological trauma, microsurgical resection of cavernomas canbe guided by the novel clinical application of a 3D Slicer with Sina/MosoCam. When cavernomas present in deep lesions with poor accessibility, gamma knife stereotactic radiosurgery (GKSR) is recommended. For asymptomatic and non-multilobal lesions, medical and symptom management is deemed standard, such as antiepileptic therapy. The two-hit hypothesis serves to explain the mutations in three key genes that are most pertinent to the progression of cavernomas: CCM1/KRIT1, CCM2/Malcavernin, and CCM3/PDCD10. Various exon deletions and frameshift mutations can cause dysfunction in vascular structure through loss and gain of function mutations. MEKK3 and KLF2/4 are involved in a protein kinase signaling cycle that promotes abnormal angiogenesis and cavernoma formation. In terms of potential treatments, RhoKinase inhibitors have shown to decrease endothelial to mesenchymal transition and CCM lesion development in mice models. All in all, understanding the research behind the molecular genetics in CCMs can foster personalized medicine and potentially create new neurosurgical and medicative treatments.
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Affiliation(s)
- Anjali Patel
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
| | - Daisy Valle
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
| | - Andrew Nguyen
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
| | - Eduardo Molina
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, College of Medicine, University of Florida, Florida 32013, United States
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Marques LL, Jaeggi C, Branca M, Raabe A, Bervini D, Goldberg J. Bleeding Risk of Cerebral Cavernous Malformations in Patients on Statin and Antiplatelet Medication: A Cohort Study. Neurosurgery 2023; 93:699-705. [PMID: 36999926 DOI: 10.1227/neu.0000000000002480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/08/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Statin medication has been identified as a potential therapeutic target for stabilizing cerebral cavernous malformations (CCMs). Although increasing evidence suggests that antiplatelet medication decreases the risk of CCM hemorrhage, data on statin medication in clinical studies are scarce. OBJECTIVE To assess the risk of symptomatic CCM-related hemorrhage at presentation and during follow-up in patients on statin and antiplatelet medication. METHODS A single-center database containing patients harboring CCMs was retrospectively analyzed over 41 years and interrogated for symptomatic hemorrhage at diagnosis, during follow-up, and statin and antiplatelet medication. RESULTS In total, 212 of 933 CCMs (22.7%), harbored by 688 patients, presented with hemorrhage at diagnosis. Statin medication was not associated with a decreased risk of hemorrhage at diagnosis (odds ratio [OR] 0.63, CI 0.23-1.69, P = .355); antiplatelet medication (OR 0.26, CI 0.08-0.86, P = .028) and combined statin and antiplatelet medication (OR 0.19, CI 0.05-0.66; P = .009) showed a decreased risk. In the antiplatelet-only group, 2 (4.7%) of 43 CCMs developed follow-up hemorrhage during 137.1 lesion-years compared with 67 (9.5%) of 703 CCMs during 3228.1 lesion-years in the nonmedication group. No follow-up hemorrhages occurred in the statin and the combined statin and antiplatelet medication group. Antiplatelet medication was not associated with follow-up hemorrhage (hazard ratio [HR] 0.7, CI 0.16-3.05; P = .634). CONCLUSION Antiplatelet medication alone and its combination with statins were associated with a lower risk of hemorrhage at CCM diagnosis. The risk reduction of combined statin and antiplatelet medication was greater than in patients receiving antiplatelet medication alone, indicating a possible synergistic effect. Antiplatelet medication alone was not associated with follow-up hemorrhage.
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Affiliation(s)
- Luca Lee Marques
- Department of Neurosurgery, Kantonsspital St. Gallen, Sankt Gallen, Switzerland
| | - Christian Jaeggi
- Department of Neurosurgery and Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Bern , Switzerland
- Department of Internal Medicine, Kantonspital Olten, Olten, Switzerland
| | | | - Andreas Raabe
- Department of Neurosurgery and Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Bern , Switzerland
| | - David Bervini
- Department of Neurosurgery and Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Bern , Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery and Stroke Research Center Bern, Inselspital, Bern University Hospital, University of Bern, Bern , Switzerland
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Anderson B, Rosston P, Ong HW, Hossain MA, Davis-Gilbert ZW, Drewry DH. How many kinases are druggable? A review of our current understanding. Biochem J 2023; 480:1331-1363. [PMID: 37642371 PMCID: PMC10586788 DOI: 10.1042/bcj20220217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
There are over 500 human kinases ranging from very well-studied to almost completely ignored. Kinases are tractable and implicated in many diseases, making them ideal targets for medicinal chemistry campaigns, but is it possible to discover a drug for each individual kinase? For every human kinase, we gathered data on their citation count, availability of chemical probes, approved and investigational drugs, PDB structures, and biochemical and cellular assays. Analysis of these factors highlights which kinase groups have a wealth of information available, and which groups still have room for progress. The data suggest a disproportionate focus on the more well characterized kinases while much of the kinome remains comparatively understudied. It is noteworthy that tool compounds for understudied kinases have already been developed, and there is still untapped potential for further development in this chemical space. Finally, this review discusses many of the different strategies employed to generate selectivity between kinases. Given the large volume of information available and the progress made over the past 20 years when it comes to drugging kinases, we believe it is possible to develop a tool compound for every human kinase. We hope this review will prove to be both a useful resource as well as inspire the discovery of a tool for every kinase.
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Affiliation(s)
- Brian Anderson
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, U.S.A
| | - Peter Rosston
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, U.S.A
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, U.S.A
| | - Han Wee Ong
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, U.S.A
| | - Mohammad Anwar Hossain
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, U.S.A
| | - Zachary W. Davis-Gilbert
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, U.S.A
| | - David H. Drewry
- Structural Genomics Consortium, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, U.S.A
- UNC Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, U.S.A
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Hage S, Kinkade S, Girard R, Flemming KD, Kim H, Torbey MT, Huang J, Huston J, Shu Y, Selwyn RG, Hart BL, Mabray MC, Feghali J, Sair HI, Narvid J, Lupo JM, Lee J, Stadnik A, Alcazar R, Shenkar R, Hobson N, DeBiasse D, Lane K, McBee N, Treine K, Ostapkovich N, Wang Y, Thompson RE, Mendoza-Puccini C, Koenig J, Carroll T, Hanley DF, Awad IA. Cavernous Angioma Symptomatic Hemorrhage (CASH) Trial Readiness II: Imaging Biomarkers and Trial Modeling. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.01.23290854. [PMID: 37333396 PMCID: PMC10275015 DOI: 10.1101/2023.06.01.23290854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Background Quantitative susceptibility mapping (QSM) and dynamic contrast enhanced quantitative perfusion (DCEQP) MRI sequences assessing iron deposition and vascular permeability were previously correlated with new hemorrhage in cavernous angiomas. We assessed their prospective changes in cavernous angiomas with symptomatic hemorrhage (CASH) in a multisite trial readiness project ( clinicaltrials.gov NCT03652181 ). Methods Patients with CASH in the prior year, without prior or planned lesion resection or irradiation were enrolled. Mean QSM and DCEQP of CASH lesion were acquired at baseline, and at 1- and 2-year follow-ups. Sensitivity and specificity of biomarker changes were analyzed in relation to predefined lesional symptomatic hemorrhage (SH) or asymptomatic change (AC). Sample size calculations for hypothesized therapeutic effects were conducted. Results We logged 143 QSM and 130 DCEQP paired annual assessments. Annual QSM change was greater in cases with SH than in cases without SH (p= 0.019). Annual QSM increase by ≥ 6% occurred in 7 of 7 cases (100%) with recurrent SH and in 7 of 10 cases (70%) with AC during the same epoch, and 3.82 times more frequently than clinical events. DCEQP change had lower sensitivity for SH and AC than QSM change, and greater variance. A trial with smallest sample size would detect a 30% difference in QSM annual change in 34 or 42 subjects (one and two-tailed, respectively), power 0.8, alpha 0.05. Conclusions Assessment of QSM change is feasible and sensitive to recurrent bleeding in CASH. Evaluation of an intervention on QSM percent change may be used as a time-averaged difference between 2 arms using a repeated measures analysis. DCEQP change is associated with lesser sensitivity and higher variability than QSM. These results are the basis of an application for certification by the U.S. F.D.A. of QSM as a biomarker of drug effect in CASH.
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Qi C, Bujaroski RS, Baell J, Zheng X. Kinases in cerebral cavernous malformations: Pathogenesis and therapeutic targets. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2023; 1870:119488. [PMID: 37209718 DOI: 10.1016/j.bbamcr.2023.119488] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/03/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023]
Abstract
Cerebral cavernous malformations (CCMs) are low-flow, hemorrhagic vascular lesions of the central nervous system of genetic origin, which can cause stroke-like symptoms and seizures. From the identification of CCM1, CCM2 and CCM3 as genes related to disease progression, molecular and cellular mechanisms for CCM pathogenesis have been established and the search for potential drugs to target CCM has begun. Broadly speaking, kinases are the major group signaling in CCM pathogenesis. These include the MEKK3/MEK5/ERK5 cascade, Rho/Rock signaling, CCM3/GCKIII signaling, PI3K/mTOR signaling, and others. Since the discovery of Rho/Rock in CCM pathogenesis, inhibitors for Rho signaling and subsequently other components in CCM signaling were discovered and applied in preclinical and clinical trials to ameliorate CCM progression. This review discusses the general aspects of CCM disease, kinase-mediated signaling in CCM pathogenesis and the current state of potential treatment options for CCM. It is suggested that kinase target drug development in the context of CCM might facilitate and meet the unmet requirement - a non-surgical option for CCM disease.
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Affiliation(s)
- Chunxiao Qi
- Department of Pharmacology and Tianjin Key Laboratory of Inflammation Biology, School of Basic Medical Sciences, Tianjin Medical University, 300070, China
| | - Richard Sean Bujaroski
- Medicinal Chemistry Theme, Monash Institute of Pharmaceutical Sciences, Australian Translational Medicinal Chemistry Facility (ATMCF), Monash University, Parkville, Victoria, Australia
| | - Jonathan Baell
- School of Pharmaceutical Sciences, Nanjing Tech University, No. 30 South Puzhu Road, Nanjing 211816, China
| | - Xiangjian Zheng
- Department of Pharmacology and Tianjin Key Laboratory of Inflammation Biology, School of Basic Medical Sciences, Tianjin Medical University, 300070, China.
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11
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Cerebral cavernous malformation: Management, outcomes, and surveillance strategies - A single centre retrospective cohort study. Clin Neurol Neurosurg 2023; 225:107576. [PMID: 36608471 DOI: 10.1016/j.clineuro.2022.107576] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) may undergo a period of clinical and/or radiographical surveillance that precedes or follows definitive treatment. There are no international guidelines on the optimal surveillance strategy. This study describes the surveillance strategies at our centre and explore the related clinical outcomes. METHODS We performed a retrospective study of adult patients with CCMs referred to a neurovascular service over an 8-year period, to determine the frequency and type of surveillance, intervention, and explore the associated outcomes. We report our findings adhering to STROBE guidelines. RESULTS 133 patients (Male:Female 73:60; men age 42 years; range 12-82) were included. CCMs were identified in patients first presenting with symptomatic intracerebral haemorrhage (42.11%); headache, focal neurological deficit, or seizure without haemorrhage (41.35%); or, as an incidental finding (16.54%). The most common CCM location was supratentorial (59.40%), followed by brain stem (21.80%), cerebellum (10.53%) and basal ganglia (6.02%). Of the 133 patients, 77 patients (57.89%) were managed conservatively, 49 patients (36.84%) were managed by surgical resection alone, and seven patients (5.26%) were managed with stereotactic radiosurgery (SRS). Patients follow-up had a mean duration of 65.94 months, and varied widely (SD = 52.59; range 0-265), for a total of 730.83 person-years of follow up. During surveillance, 16 patients suffered an ICH equating to a bleeding rate of 2.19 per 100 patient years. CCMs that increased in size had a higher bleeding rate (p = 8.58 ×10-4). There were 8 (6.02%) cases where routine clinic review or MRI resulted in a change in management. CONCLUSIONS Our single centre retrospective study supports existing literature relating to presentation and sequalae of CCM, with an increase in CCM size being associated with higher rates of detected bleeding. There remains heterogeneity, even within a single centre, on the frequency and modality of surveillance. Further, there are no international guidelines or high-quality data that recommends the optimal duration and frequency of surveillance, and its effect on clinical outcomes. This is a future research direction.
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12
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Capitanio JF, Mortini P. Brain and/or Spinal Cord Tumors Accompanied with Other Diseases or Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1405:645-672. [PMID: 37452957 DOI: 10.1007/978-3-031-23705-8_25] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Several medical conditions that interest both the brain and the spinal cord have been described throughout the history of medicine. Formerly grouped under the term Phacomatosis because lesions of the eye were frequently encountered or genodermatosis when typical skin lesions were present, these terms have been progressively discarded. Although originally reported centuries ago, they still represent a challenge for their complexity of cure. Nowadays, with the introduction of advanced genetics and the consequent opportunity of whole-genome sequencing, new single cancer susceptibility genes have been identified or better characterized; although there is evidence that the predisposition to a few specific tumor syndromes should be accounted to a group of mutations in different genes while certain syndromes appeared to be manifestations of different mutations in the same gene adding supplementary problems in their characterization and establishing the diagnosis. Noteworthy, many syndromes have been genetically determined and well-characterized, accordingly in the near future, we expect that new targeted therapies will be available for the definitive cure of these syndromes and other gliomas (Pour-Rashidi et al. in World Neurosurgery, 2021). The most common CNS syndromes that will be discussed in this chapter include neurofibromatosis (NF) types 1 and 2, von Hippel-Lindau (VHL) disease, and tuberous sclerosis complex (TSC), as well as syndromes having mostly extra-neural manifestations such as Cowden, Li-Fraumeni, Turcot, and Gorlin syndromes.
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Affiliation(s)
- Jody Filippo Capitanio
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy.
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
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13
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Lai CC, Nelsen B, Frias-Anaya E, Gallego-Gutierrez H, Orecchioni M, Herrera V, Ortiz E, Sun H, Mesarwi OA, Ley K, Gongol B, Lopez-Ramirez MA. Neuroinflammation Plays a Critical Role in Cerebral Cavernous Malformation Disease. Circ Res 2022; 131:909-925. [PMID: 36285625 PMCID: PMC9669201 DOI: 10.1161/circresaha.122.321129] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 10/11/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Cerebral cavernous malformations (CCMs) are neurovascular lesions caused by loss of function mutations in 1 of 3 genes, including KRIT1 (CCM1), CCM2, and PDCD10 (CCM3). CCMs affect ≈1 out of 200 children and adults, and no pharmacologic therapy is available. CCM lesion count, size, and aggressiveness vary widely among patients of similar ages with the same mutation or even within members of the same family. However, what determines the transition from quiescent lesions into mature and active (aggressive) CCM lesions is unknown. METHODS We use genetic, RNA-sequencing, histology, flow cytometry, and imaging techniques to report the interaction between CCM endothelium, astrocytes, leukocytes, microglia/macrophages, neutrophils (CCM endothelium, astrocytes, leukocytes, microglia/macrophages, neutrophils interaction) during the pathogenesis of CCMs in the brain tissue. RESULTS Expression profile of astrocytes in adult mouse brains using translated mRNAs obtained from the purification of EGFP (enhanced green fluorescent protein)-tagged ribosomes (Aldh1l1-EGFP/Rpl10a) in the presence or absence of CCM lesions (Slco1c1-iCreERT2;Pdcd10fl/fl; Pdcd10BECKO) identifies a novel gene signature for neuroinflammatory astrocytes. CCM-induced reactive astrocytes have a neuroinflammatory capacity by expressing genes involved in angiogenesis, chemotaxis, hypoxia signaling, and inflammation. RNA-sequencing analysis on RNA isolated from brain endothelial cells in chronic Pdcd10BECKO mice (CCM endothelium), identified crucial genes involved in recruiting inflammatory cells and thrombus formation through chemotaxis and coagulation pathways. In addition, CCM endothelium was associated with increased expression of Nlrp3 and Il1b. Pharmacological inhibition of NLRP3 (NOD [nucleotide-binding oligomerization domain]-' LRR [leucine-rich repeat]- and pyrin domain-containing protein 3) significantly decreased inflammasome activity as assessed by quantification of a fluorescent indicator of caspase-1 activity (FAM-FLICA [carboxyfluorescein-fluorochrome-labeled inhibitors of caspases] caspase-1) in brain endothelial cells from Pdcd10BECKO in chronic stage. Importantly, our results support the hypothesis of the crosstalk between astrocytes and CCM endothelium that can trigger recruitment of inflammatory cells arising from brain parenchyma (microglia) and the peripheral immune system (leukocytes) into mature active CCM lesions that propagate lesion growth, immunothrombosis, and bleedings. Unexpectedly, partial or total loss of brain endothelial NF-κB (nuclear factor κB) activity (using Ikkbfl/fl mice) in chronic Pdcd10BECKO mice does not prevent lesion genesis or neuroinflammation. Instead, this resulted in a trend increase in the number of lesions and immunothrombosis, suggesting that therapeutic approaches designed to target inflammation through endothelial NF-κB inhibition may contribute to detrimental side effects. CONCLUSIONS Our study reveals previously unknown links between neuroinflammatory astrocytes and inflamed CCM endothelium as contributors that trigger leukocyte recruitment and precipitate immunothrombosis in CCM lesions. However, therapeutic approaches targeting brain endothelial NF-κB activity may contribute to detrimental side effects.
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Affiliation(s)
| | - Bliss Nelsen
- Department of Medicine, University of California, San
Diego, La Jolla, California, USA
| | - Eduardo Frias-Anaya
- Department of Medicine, University of California, San
Diego, La Jolla, California, USA
| | | | - Marco Orecchioni
- Division of Inflammation Biology, La Jolla Institute for
Immunology, La Jolla, California, USA
| | - Victoria Herrera
- Department of Medicine, University of California, San
Diego, La Jolla, California, USA
| | - Elan Ortiz
- Department of Medicine, University of California, San
Diego, La Jolla, California, USA
| | - Hao Sun
- Department of Medicine, University of California, San
Diego, La Jolla, California, USA
| | - Omar A. Mesarwi
- Department of Medicine, University of California, San
Diego, La Jolla, California, USA
| | - Klaus Ley
- Division of Inflammation Biology, La Jolla Institute for
Immunology, La Jolla, California, USA
| | - Brendan Gongol
- Department of Health Sciences, Victor Valley College,
Victorville, California, USA
- Institute for Integrative Genome Biology, 1207F Genomics
Building, University of California, Riverside, CA 92521, USA
| | - Miguel Alejandro Lopez-Ramirez
- Department of Medicine, University of California, San
Diego, La Jolla, California, USA
- Department of Pharmacology, University of California, San
Diego, La Jolla, California, USA
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14
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Pillay LM, Yano JJ, Davis AE, Butler MG, Ezeude MO, Park JS, Barnes KA, Reyes VL, Castranova D, Gore AV, Swift MR, Iben JR, Kenton MI, Stratman AN, Weinstein BM. In vivo dissection of Rhoa function in vascular development using zebrafish. Angiogenesis 2022; 25:411-434. [PMID: 35320450 DOI: 10.1007/s10456-022-09834-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 02/22/2022] [Indexed: 12/27/2022]
Abstract
The small monomeric GTPase RHOA acts as a master regulator of signal transduction cascades by activating effectors of cellular signaling, including the Rho-associated protein kinases ROCK1/2. Previous in vitro cell culture studies suggest that RHOA can regulate many critical aspects of vascular endothelial cell (EC) biology, including focal adhesion, stress fiber formation, and angiogenesis. However, the specific in vivo roles of RHOA during vascular development and homeostasis are still not well understood. In this study, we examine the in vivo functions of RHOA in regulating vascular development and integrity in zebrafish. We use zebrafish RHOA-ortholog (rhoaa) mutants, transgenic embryos expressing wild type, dominant negative, or constitutively active forms of rhoaa in ECs, pharmacological inhibitors of RHOA and ROCK1/2, and Rock1 and Rock2a/b dgRNP-injected zebrafish embryos to study the in vivo consequences of RHOA gain- and loss-of-function in the vascular endothelium. Our findings document roles for RHOA in vascular integrity, developmental angiogenesis, and vascular morphogenesis in vivo, showing that either too much or too little RHOA activity leads to vascular dysfunction.
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Affiliation(s)
- Laura M Pillay
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Joseph J Yano
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
- Department of Cell and Molecular Biology, University of Pennsylvania, 440 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Andrew E Davis
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Matthew G Butler
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Megan O Ezeude
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Jong S Park
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Keith A Barnes
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Vanessa L Reyes
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Daniel Castranova
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Aniket V Gore
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Matthew R Swift
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - James R Iben
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Madeleine I Kenton
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
| | - Amber N Stratman
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA
- Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Brant M Weinstein
- Division of Developmental Biology, National Institute of Child Health and Human Development, National Institutes of Health, 6 Center Dr. Bethesda, Bethesda, MD, 20892, USA.
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15
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Bagnell AM, Sumner CJ, McCray BA. TRPV4: A trigger of pathological RhoA activation in neurological disease. Bioessays 2022; 44:e2100288. [PMID: 35297520 PMCID: PMC9295809 DOI: 10.1002/bies.202100288] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/03/2022] [Accepted: 03/07/2022] [Indexed: 12/14/2022]
Abstract
Transient receptor potential vanilloid 4 (TRPV4), a member of the TRP superfamily, is a broadly expressed, cell surface-localized cation channel that is activated by a variety of environmental stimuli. Importantly, TRPV4 has been increasingly implicated in the regulation of cellular morphology. Here we propose that TRPV4 and the cytoskeletal remodeling small GTPase RhoA together constitute an environmentally sensitive signaling complex that contributes to pathological cell cytoskeletal alterations during neurological injury and disease. Supporting this hypothesis is our recent work demonstrating direct physical and bidirectional functional interactions of TRPV4 with RhoA, which can lead to activation of RhoA and reorganization of the actin cytoskeleton. Furthermore, a confluence of evidence implicates TRPV4 and/or RhoA in pathological responses triggered by a range of acute neurological insults ranging from stroke to traumatic injury. While initiated by a variety of insults, TRPV4-RhoA signaling may represent a common pathway that disrupts axonal regeneration and blood-brain barrier integrity. These insights also suggest that TRPV4 inhibition may represent a safe, feasible, and precise therapeutic strategy for limiting pathological TRPV4-RhoA activation in a range of neurological diseases.
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Affiliation(s)
- Anna M. Bagnell
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charlotte J. Sumner
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brett A. McCray
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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16
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Tailored Treatment Options for Cerebral Cavernous Malformations. J Pers Med 2022; 12:jpm12050831. [PMID: 35629253 PMCID: PMC9147523 DOI: 10.3390/jpm12050831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/02/2022] [Accepted: 05/13/2022] [Indexed: 11/19/2022] Open
Abstract
The diagnosis and treatment of cerebral cavernous malformations (CCMs), or cavernomas, continues to evolve as more data and treatment modalities become available. Intervention is necessary when a lesion causes symptomatic neurologic deficits, seizures, or has high risk of continued hemorrhage. Future medical treatment directions may specifically target the pathogenesis of these lesions. This review highlights the importance of individualized treatment plans based on specific CCM characteristics.
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17
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Hagan M, Shenkar R, Srinath A, Romanos SG, Stadnik A, Kahn ML, Marchuk DA, Girard R, Awad IA. Rapamycin in Cerebral Cavernous Malformations: What Doses to Test in Mice and Humans. ACS Pharmacol Transl Sci 2022; 5:266-277. [PMID: 35592432 PMCID: PMC9112291 DOI: 10.1021/acsptsci.2c00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Indexed: 11/29/2022]
Abstract
Cerebral cavernous malformations (CCMs) are hemorrhagic neurovascular lesions that affect more than 1 million people in the United States. Rapamycin inhibits CCM development and bleeding in murine models. The appropriate dosage to modify disease phenotype remains unknown. Current approved indications by the U.S. Food and Drug Administration and clinicaltrials.gov were queried for rapamycin human dosing for various indications. A systematic literature search was conducted on PubMed to investigate mouse dosimetry of rapamycin. In humans, low daily doses of <2 mg/day or trough level targets <15 ng/mL were typically used for benign indications akin to CCM disease, with relatively low complication rates. Higher oral doses in humans, used for organ rejection, result in higher complication rates. Oral dosing in mice, between 2 and 4 mg/kg/day, achieved blood trough levels in the 5-15 ng/mL range, a concentration likely to be targeted in human studies to treat CCM. Preclinical studies are needed utilizing dosing strategies which achieve blood levels corresponding to likely human dosimetry.
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Affiliation(s)
- Matthew
J. Hagan
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Robert Shenkar
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Abhinav Srinath
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Sharbel G. Romanos
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Agnieszka Stadnik
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Mark L. Kahn
- Department
of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Douglas A. Marchuk
- Department
of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina 27710, United States
| | - Romuald Girard
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
| | - Issam A. Awad
- Neurovascular
Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, United States
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18
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Fang Z, Sun X, Wang X, Ma J, Palaia T, Rana U, Miao B, Ragolia L, Hu W, Miao QR. NOGOB receptor deficiency increases cerebrovascular permeability and hemorrhage via impairing histone acetylation-mediated CCM1/2 expression. J Clin Invest 2022; 132:e151382. [PMID: 35316220 PMCID: PMC9057619 DOI: 10.1172/jci151382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 03/16/2022] [Indexed: 11/17/2022] Open
Abstract
The loss function of cerebral cavernous malformation (CCM) genes leads to most CCM lesions characterized by enlarged leaking vascular lesions in the brain. Although we previously showed that NOGOB receptor (NGBR) knockout in endothelial cells (ECs) results in cerebrovascular lesions in the mouse embryo, the molecular mechanism by which NGBR regulates CCM1/2 expression has not been elucidated. Here, we show that genetic depletion of Ngbr in ECs at both postnatal and adult stages results in CCM1/2 expression deficiency and cerebrovascular lesions such as enlarged vessels, blood-brain-barrier hyperpermeability, and cerebral hemorrhage. To reveal the molecular mechanism, we used RNA-sequencing analysis to examine changes in the transcriptome. Surprisingly, we found that the acetyltransferase HBO1 and histone acetylation were downregulated in NGBR-deficient ECs. The mechanistic studies elucidated that NGBR is required for maintaining the expression of CCM1/2 in ECs via HBO1-mediated histone acetylation. ChIP-qPCR data further demonstrated that loss of NGBR impairs the binding of HBO1 and acetylated histone H4K5 and H4K12 on the promotor of the CCM1 and CCM2 genes. Our findings on epigenetic regulation of CCM1 and CCM2 that is modulated by NGBR and HBO1-mediated histone H4 acetylation provide a perspective on the pathogenesis of sporadic CCMs.
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Affiliation(s)
- Zhi Fang
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Xiaoran Sun
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Xiang Wang
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ji Ma
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Thomas Palaia
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Ujala Rana
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Benjamin Miao
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Louis Ragolia
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Wenquan Hu
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Qing Robert Miao
- Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, New York, USA
- Department of Surgery and Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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19
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Phillips CM, Stamatovic SM, Keep RF, Andjelkovic AV. Cerebral Cavernous Malformation Pathogenesis: Investigating Lesion Formation and Progression with Animal Models. Int J Mol Sci 2022; 23:5000. [PMID: 35563390 PMCID: PMC9105545 DOI: 10.3390/ijms23095000] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/25/2022] [Accepted: 04/28/2022] [Indexed: 02/01/2023] Open
Abstract
Cerebral cavernous malformation (CCM) is a cerebromicrovascular disease that affects up to 0.5% of the population. Vessel dilation, decreased endothelial cell-cell contact, and loss of junctional complexes lead to loss of brain endothelial barrier integrity and hemorrhagic lesion formation. Leakage of hemorrhagic lesions results in patient symptoms and complications, including seizures, epilepsy, focal headaches, and hemorrhagic stroke. CCMs are classified as sporadic (sCCM) or familial (fCCM), associated with loss-of-function mutations in KRIT1/CCM1, CCM2, and PDCD10/CCM3. Identifying the CCM proteins has thrust the field forward by (1) revealing cellular processes and signaling pathways underlying fCCM pathogenesis, and (2) facilitating the development of animal models to study CCM protein function. CCM animal models range from various murine models to zebrafish models, with each model providing unique insights into CCM lesion development and progression. Additionally, these animal models serve as preclinical models to study therapeutic options for CCM treatment. This review briefly summarizes CCM disease pathology and the molecular functions of the CCM proteins, followed by an in-depth discussion of animal models used to study CCM pathogenesis and developing therapeutics.
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Affiliation(s)
- Chelsea M. Phillips
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
| | - Svetlana M. Stamatovic
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
| | - Richard F. Keep
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
- Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Anuska V. Andjelkovic
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
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20
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Zuurbier SM, Hickman CR, Rinkel LA, Berg R, Sure U, Al-Shahi Salman R. Association Between Beta-Blocker or Statin Drug Use and the Risk of Hemorrhage From Cerebral Cavernous Malformations. Stroke 2022; 53:2521-2527. [PMID: 35410492 PMCID: PMC9311291 DOI: 10.1161/strokeaha.121.037009] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aimed to determine the association between beta-blocker or statin drug use and the future risk of symptomatic intracranial hemorrhage or persistent/progressive focal neurological deficit from cerebral cavernous malformations (CCM). METHODS The population-based Scottish Audit of Intracranial Vascular Malformations prospectively identified adults resident in Scotland first diagnosed with CCM during 1999 to 2003 or 2006 to 2010. We compared the association between beta-blocker or statin drug use after first presentation and the occurrence of new intracranial hemorrhage or persistent/progressive focal neurological deficit due to CCM for up to 15 years of prospective follow-up. We confirmed proportional hazards and used survival analysis with multivariable adjustment for age, intracranial hemorrhage at CCM presentation, and brain stem CCM location. RESULTS Sixty-three (21%) of 300 adults used beta-blockers (27/63 [43%] used propranolol), and 73 (24%) used statin drugs over 3634 person-years of follow-up. At baseline, the only statistically significant imbalances in prespecified potential confounders were age by statin use and intracranial hemorrhage at presentation by beta-blocker use. Beta-blocker use was associated with a lower risk of new intracranial hemorrhage or persistent/progressive focal neurological deficit (adjusted hazard ratio, 0.09 [95% CI, 0.01-0.66]; P=0.018). Statin use was associated with a nonsignificant lower risk of intracranial hemorrhage or persistent/progressive focal neurological deficit (adjusted hazard ratio, 0.37 [95% CI, 0.01-1.07]; P=0.067). CONCLUSIONS Beta-blocker, but not statin, use was associated with a lower risk of intracranial hemorrhage or persistent/progressive focal neurological deficit in patients with CCM.
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Affiliation(s)
- Susanna M Zuurbier
- Department of Neurology, Amsterdam University Medical Center, The Netherlands (S.M.Z., L.A.R.)
| | - Charlotte R Hickman
- Edinburgh Medical School, College of Medicine and Veterinary Medicine (C.R.H.)
| | - Leon A Rinkel
- Department of Neurology, Amsterdam University Medical Center, The Netherlands (S.M.Z., L.A.R.)
| | - Rebecca Berg
- University of Edinburgh, United Kingdom. Department of Neurosurgery, University of Duisburg-Essen, Germany (R.B., U.S.)
| | - Ulrich Sure
- University of Edinburgh, United Kingdom. Department of Neurosurgery, University of Duisburg-Essen, Germany (R.B., U.S.)
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences and Usher Institute of Population Health Sciences and Informatics (R.A.-S.S.)
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21
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Cheng D, Shang X, Gao W, Barkhof F, Liu Y. Fetal Familial Cerebral Cavernous Malformation With a Novel Heterozygous KRIT1 Variation. Neurology 2021; 97:986-988. [PMID: 34556564 DOI: 10.1212/wnl.0000000000012852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To identify fetal familial cerebral cavernous malformation (CCM) and a novel variation. METHODS A 37-year-old pregnant woman (G4P0) presented with right-handed numbness since 2 weeks at 31 weeks of gestation. Evaluation with brain MRI revealed multiple CCMs. As a result, fetal MRI, fetal whole exome sequencing, and maternal Sanger sequencing were performed. RESULTS The mother's brain MRI demonstrated numerous CCMs involving the brain stem, cerebral hemispheres, and cerebellum. Fetal MRI showed a CCM located in the left frontal lobe in susceptibility-weighted imaging (SWI). The neuroimaging characteristics of the mother and the fetus suggested that their CCMs may be familial. Genetic analysis revealed a novel variation in KRIT1 (c.1A>G, p.0?), also called CCM1, in the mother and the baby. The mother delivered a daughter at 32 weeks of gestation with an Apgar score of 10 by cesarean section. DISCUSSION This variation of the initial codon in the KRIT1 gene leads to a phenotype with an early-onset. To our knowledge, this is the first-ever reported case of fetal familial CCM and this novel variation. Brain MRI has excellent sensitivity and specificity, providing the best option for detecting CCMs, even in utero, primarily when SWI is used.
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Affiliation(s)
- Dan Cheng
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands
| | - Xiang Shang
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands
| | - Wanli Gao
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands
| | - Frederik Barkhof
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands
| | - Yaou Liu
- From the Departments of Radiology (D.C., Y.L.), and Obstetrics (X.S., W.G.), Beijing Tiantan Hospital, Capital Medical University, China; UCL Institutes of Neurology and Healthcare Engineering (F.B.), London, United Kingdom; and Department of Radiology and Nuclear Medicine (F.B.), Amsterdam University Medical Centers, the Netherlands.
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22
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Venugopal V, Sumi S. Molecular Biomarkers and Drug Targets in Brain Arteriovenous and Cavernous Malformations: Where Are We? Stroke 2021; 53:279-289. [PMID: 34784742 DOI: 10.1161/strokeaha.121.035654] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Vascular malformations of the brain (VMB) comprise abnormal development of blood vessels. A small fraction of VMBs causes hemorrhages with neurological morbidity and risk of mortality in patients. Most often, they are symptomatically silent and are detected at advanced stages of disease progression. The most common forms of VMBs are arteriovenous and cavernous malformations in the brain. Radiopathological features of these diseases are complex with high phenotypic variability. Early detection of these malformations followed by preclusion of severe neurological deficits such as hemorrhage and stroke is crucial in the clinical management of patients with VMBs. The technological advances in high-throughput omics platforms have currently infused a zest in translational research in VMBs. Besides finding novel biomarkers and therapeutic targets, these studies have withal contributed significantly to the understanding of the etiopathogenesis of VMBs. Here we discuss the recent advances in predictive and prognostic biomarker research in sporadic and familial arteriovenous malformations as well as cerebral cavernous malformations. Furthermore, we analyze the clinical applicability of protein and noncoding RNA-based molecular-targeted therapies which may have a potentially key role in disease management.
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Affiliation(s)
- Vani Venugopal
- Rajiv Gandhi Center for Biotechnology, Thiruvananthapuram, Kerala, India
| | - S Sumi
- Rajiv Gandhi Center for Biotechnology, Thiruvananthapuram, Kerala, India
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23
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Archie SR, Al Shoyaib A, Cucullo L. Blood-Brain Barrier Dysfunction in CNS Disorders and Putative Therapeutic Targets: An Overview. Pharmaceutics 2021; 13:pharmaceutics13111779. [PMID: 34834200 PMCID: PMC8622070 DOI: 10.3390/pharmaceutics13111779] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 01/22/2023] Open
Abstract
The blood-brain barrier (BBB) is a fundamental component of the central nervous system (CNS). Its functional and structural integrity is vital to maintain the homeostasis of the brain microenvironment by controlling the passage of substances and regulating the trafficking of immune cells between the blood and the brain. The BBB is primarily composed of highly specialized microvascular endothelial cells. These cells’ special features and physiological properties are acquired and maintained through the concerted effort of hemodynamic and cellular cues from the surrounding environment. This complex multicellular system, comprising endothelial cells, astrocytes, pericytes, and neurons, is known as the neurovascular unit (NVU). The BBB strictly controls the transport of nutrients and metabolites into brain parenchyma through a tightly regulated transport system while limiting the access of potentially harmful substances via efflux transcytosis and metabolic mechanisms. Not surprisingly, a disruption of the BBB has been associated with the onset and/or progression of major neurological disorders. Although the association between disease and BBB disruption is clear, its nature is not always evident, specifically with regard to whether an impaired BBB function results from the pathological condition or whether the BBB damage is the primary pathogenic factor prodromal to the onset of the disease. In either case, repairing the barrier could be a viable option for treating and/or reducing the effects of CNS disorders. In this review, we describe the fundamental structure and function of the BBB in both healthy and altered/diseased conditions. Additionally, we provide an overview of the potential therapeutic targets that could be leveraged to restore the integrity of the BBB concomitant to the treatment of these brain disorders.
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Affiliation(s)
- Sabrina Rahman Archie
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA; (S.R.A.); (A.A.S.)
| | - Abdullah Al Shoyaib
- Department of Pharmaceutical Sciences, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA; (S.R.A.); (A.A.S.)
| | - Luca Cucullo
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA
- Correspondence: ; Tel.: +1-248-370-3884; Fax: +1-248-370-4060
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24
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Emerging role of ferroptosis in breast cancer: New dawn for overcoming tumor progression. Pharmacol Ther 2021; 232:107992. [PMID: 34606782 DOI: 10.1016/j.pharmthera.2021.107992] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/02/2021] [Accepted: 09/07/2021] [Indexed: 02/08/2023]
Abstract
Breast cancer has become a serious threat to women's health. Cancer progression is mainly derived from resistance to apoptosis induced by procedures or therapies. Therefore, new drugs or models that can overcome apoptosis resistance should be identified. Ferroptosis is a recently identified mode of cell death characterized by excess reactive oxygen species-induced lipid peroxidation. Since ferroptosis is distinct from apoptosis, necrosis and autophagy, its induction successfully eliminates cancer cells that are resistant to other modes of cell death. Therefore, ferroptosis may become a new direction around which to design breast cancer treatment. Unfortunately, the complete appearance of ferroptosis in breast cancer has not yet been fully elucidated. Furthermore, whether ferroptosis inducers can be used in combination with traditional anti- breast cancer drugs is still unknown. Moreover, a summary of ferroptosis in breast cancer progression and therapy is currently not available. In this review, we discuss the roles of ferroptosis-associated modulators glutathione, glutathione peroxidase 4, iron, nuclear factor erythroid-2 related factor-2, superoxide dismutases, lipoxygenase and coenzyme Q in breast cancer. Furthermore, we provide evidence that traditional drugs against breast cancer induce ferroptosis, and that ferroptosis inducers eliminate breast cancer cells. Finally, we put forward prospect of using ferroptosis inducers in breast cancer therapy, and predict possible obstacles and corresponding solutions. This review will deepen our understanding of the relationship between ferroptosis and breast cancer, and provide new insights into breast cancer-related therapeutic strategies.
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25
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CCM2-deficient endothelial cells undergo a ROCK-dependent reprogramming into senescence-associated secretory phenotype. Angiogenesis 2021; 24:843-860. [PMID: 34342749 DOI: 10.1007/s10456-021-09809-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
Cerebral cavernous malformation (CCM) is a cerebrovascular disease in which stacks of dilated haemorrhagic capillaries form focally in the brain. Whether and how defective mechanotransduction, cellular mosaicism and inflammation interplay to sustain the progression of CCM disease is unknown. Here, we reveal that CCM1- and CCM2-silenced endothelial cells expanded in vitro enter into senescence-associated secretory phenotype (SASP) that they use to invade the extracellular matrix and attract surrounding wild-type endothelial and immune cells. Further, we demonstrate that this SASP is driven by the cytoskeletal, molecular and transcriptomic disorders provoked by ROCK dysfunctions. By this, we propose that CCM2 and ROCK could be parts of a scaffold controlling senescence, bringing new insights into the emerging field of the control of ageing by cellular mechanics. These in vitro findings reconcile the known dysregulated traits of CCM2-deficient endothelial cells into a unique endothelial fate. Based on these in vitro results, we propose that a SASP could link the increased ROCK-dependent cell contractility in CCM2-deficient endothelial cells with microenvironment remodelling and long-range chemo-attraction of endothelial and immune cells.
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26
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Li J, Zheng M, Shimoni O, Banks WA, Bush AI, Gamble JR, Shi B. Development of Novel Therapeutics Targeting the Blood-Brain Barrier: From Barrier to Carrier. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2021; 8:e2101090. [PMID: 34085418 PMCID: PMC8373165 DOI: 10.1002/advs.202101090] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/11/2021] [Indexed: 05/05/2023]
Abstract
The blood-brain barrier (BBB) is a highly specialized neurovascular unit, initially described as an intact barrier to prevent toxins, pathogens, and potentially harmful substances from entering the brain. An intact BBB is also critical for the maintenance of normal neuronal function. In cerebral vascular diseases and neurological disorders, the BBB can be disrupted, contributing to disease progression. While restoration of BBB integrity serves as a robust biomarker of better clinical outcomes, the restrictive nature of the intact BBB presents a major hurdle for delivery of therapeutics into the brain. Recent studies show that the BBB is actively engaged in crosstalk between neuronal and the circulatory systems, which defines another important role of the BBB: as an interfacing conduit that mediates communication between two sides of the BBB. This role has been subject to extensive investigation for brain-targeted drug delivery and shows promising results. The dual roles of the BBB make it a unique target for drug development. Here, recent developments and novel strategies to target the BBB for therapeutic purposes are reviewed, from both barrier and carrier perspectives.
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Affiliation(s)
- Jia Li
- School of PharmacyHenan UniversityKaifeng475001China
- Centre for Motor Neuron DiseaseDepartment of Biomedical SciencesFaculty of Medicine & Health SciencesMacquarie UniversitySydneyNew South Wales2109Australia
| | - Meng Zheng
- Henan‐Macquarie University Joint Center for Biomedical InnovationSchool of Life SciencesHenan UniversityKaifengHenan475004China
| | - Olga Shimoni
- Institute for Biomedical Materials and DevicesSchool of Mathematical and Physical SciencesFaculty of ScienceUniversity of Technology SydneySydneyNew South Wales2007Australia
| | - William A. Banks
- Geriatric Research Education and Clinical CenterVeterans Affairs Puget Sound Health Care System and Division of Gerontology and Geriatric MedicineDepartment of MedicineUniversity of Washington School of MedicineSeattleWA98108USA
| | - Ashley I. Bush
- Melbourne Dementia Research CenterThe Florey Institute for Neuroscience and Mental HealthThe University of MelbourneParkvilleVictoria3052Australia
| | - Jennifer R. Gamble
- Center for the EndotheliumVascular Biology ProgramCentenary InstituteThe University of SydneySydneyNew South Wales2042Australia
| | - Bingyang Shi
- School of PharmacyHenan UniversityKaifeng475001China
- Centre for Motor Neuron DiseaseDepartment of Biomedical SciencesFaculty of Medicine & Health SciencesMacquarie UniversitySydneyNew South Wales2109Australia
- Henan‐Macquarie University Joint Center for Biomedical InnovationSchool of Life SciencesHenan UniversityKaifengHenan475004China
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27
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Zhang J, Abou-Fadel JS. Calm the raging hormone - A new therapeutic strategy involving progesterone-signaling for hemorrhagic CCMs. VESSEL PLUS 2021; 5:48. [PMID: 35098046 DOI: 10.20517/2574-1209.2021.64] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Cerebral cavernous malformations (CCMs), one of the most common vascular malformations, are characterized by abnormally dilated intracranial microvascular capillaries resulting in increased susceptibility to hemorrhagic stroke. As an autosomal dominant disorder with incomplete penetrance, the majority of CCMs gene mutation carriers are largely asymptomatic but when symptoms occur, the disease has typically reached the stage of focal hemorrhage with irreversible brain damage, while the molecular "trigger" initiating the occurrence of CCM pathology remain elusive. Currently, the invasive neurosurgery removal of CCM lesions is the only option for the treatment, despite the recurrence of the worse symptoms frequently occurring after surgery. Therefore, there is a grave need for identification of molecular targets for therapeutic treatment and biomarkers as risk predictors for hemorrhagic stroke prevention. Based on reported various perturbed angiogenic signaling cascades mediated by the CCM signaling complex (CSC), there have been many proposed candidate drugs, targeting potentially angiogenic-relevant signaling pathways dysregulated by loss of function of one of the CCM proteins, which might not be enough to correct the pathological phenotype, hemorrhagic CCMs. In this review, we describe a new paradigm for the mechanism of hemorrhagic CCM lesions, and propose a new concept for the assurance of the CSC-stability to prevent the devastating outcome of hemorrhagic CCMs.
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Affiliation(s)
- Jun Zhang
- Departments of Molecular & Translational Medicine (MTM), Texas Tech University Health Science Center El Paso (TTUHSCEP), El Paso, TX 79905, USA
| | - Johnathan S Abou-Fadel
- Departments of Molecular & Translational Medicine (MTM), Texas Tech University Health Science Center El Paso (TTUHSCEP), El Paso, TX 79905, USA
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28
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Snellings DA, Hong CC, Ren AA, Lopez-Ramirez MA, Girard R, Srinath A, Marchuk DA, Ginsberg MH, Awad IA, Kahn ML. Cerebral Cavernous Malformation: From Mechanism to Therapy. Circ Res 2021; 129:195-215. [PMID: 34166073 PMCID: PMC8922476 DOI: 10.1161/circresaha.121.318174] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cerebral cavernous malformations are acquired vascular anomalies that constitute a common cause of central nervous system hemorrhage and stroke. The past 2 decades have seen a remarkable increase in our understanding of the pathogenesis of this vascular disease. This new knowledge spans genetic causes of sporadic and familial forms of the disease, molecular signaling changes in vascular endothelial cells that underlie the disease, unexpectedly strong environmental effects on disease pathogenesis, and drivers of disease end points such as hemorrhage. These novel insights are the integrated product of human clinical studies, human genetic studies, studies in mouse and zebrafish genetic models, and basic molecular and cellular studies. This review addresses the genetic and molecular underpinnings of cerebral cavernous malformation disease, the mechanisms that lead to lesion hemorrhage, and emerging biomarkers and therapies for clinical treatment of cerebral cavernous malformation disease. It may also serve as an example for how focused basic and clinical investigation and emerging technologies can rapidly unravel a complex disease mechanism.
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Affiliation(s)
- Daniel A Snellings
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC (D.A.S., D.A.M.)
| | - Courtney C Hong
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia (C.C.H., A.A.R., M.L.K.)
| | - Aileen A Ren
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia (C.C.H., A.A.R., M.L.K.)
| | - Miguel A Lopez-Ramirez
- Department of Medicine (M.A.L.-R., M.H.G.), University of California, San Diego, La Jolla
- Department of Pharmacology (M.A.L.-R.), University of California, San Diego, La Jolla
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Abhinav Srinath
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Douglas A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC (D.A.S., D.A.M.)
| | - Mark H Ginsberg
- Department of Medicine (M.A.L.-R., M.H.G.), University of California, San Diego, La Jolla
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Mark L Kahn
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia (C.C.H., A.A.R., M.L.K.)
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29
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Girard R, Li Y, Stadnik A, Shenkar R, Hobson N, Romanos S, Srinath A, Moore T, Lightle R, Shkoukani A, Akers A, Carroll T, Christoforidis GA, Koenig JI, Lee C, Piedad K, Greenberg SM, Kim H, Flemming KD, Ji Y, Awad IA. A Roadmap for Developing Plasma Diagnostic and Prognostic Biomarkers of Cerebral Cavernous Angioma With Symptomatic Hemorrhage (CASH). Neurosurgery 2021; 88:686-697. [PMID: 33469662 DOI: 10.1093/neuros/nyaa478] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/16/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Cerebral cavernous angioma (CA) is a capillary microangiopathy predisposing more than a million Americans to premature risk of brain hemorrhage. CA with recent symptomatic hemorrhage (SH), most likely to re-bleed with serious clinical sequelae, is the primary focus of therapeutic development. Signaling aberrations in CA include proliferative dysangiogenesis, blood-brain barrier hyperpermeability, inflammatory/immune processes, and anticoagulant vascular domain. Plasma levels of molecules reflecting these mechanisms and measures of vascular permeability and iron deposition on magnetic resonance imaging are biomarkers that have been correlated with CA hemorrhage. OBJECTIVE To optimize these biomarkers to accurately diagnose cavernous angioma with symptomatic hemorrhage (CASH), prognosticate the risk of future SH, and monitor cases after a bleed and in response to therapy. METHODS Additional candidate biomarkers, emerging from ongoing mechanistic and differential transcriptome studies, would further enhance the sensitivity and specificity of diagnosis and prediction of CASH. Integrative combinations of levels of plasma proteins and characteristic micro-ribonucleic acids may further strengthen biomarker associations. We will deploy advanced statistical and machine learning approaches for the integration of novel candidate biomarkers, rejecting noncorrelated candidates, and determining the best clustering and weighing of combined biomarker contributions. EXPECTED OUTCOMES With the expertise of leading CA researchers, this project anticipates the development of future blood tests for the diagnosis and prediction of CASH to clinically advance towards precision medicine. DISCUSSION The project tests a novel integrational approach of biomarker development in a mechanistically defined cerebrovascular disease with a relevant context of use, with an approach applicable to other neurological diseases with similar pathobiologic features.
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Affiliation(s)
- Romuald Girard
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Yan Li
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois.,Bioinformatics core, Center for Research Informatics, University of Chicago, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Robert Shenkar
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Nicholas Hobson
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Thomas Moore
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Rhonda Lightle
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Abdallah Shkoukani
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Timothy Carroll
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Gregory A Christoforidis
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - James I Koenig
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | | | - Kristina Piedad
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Helen Kim
- Department of Anesthesia & Perioperative Care, University of California at San Francisco, San Francisco, California
| | | | - Yuan Ji
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Issam A Awad
- Neurovascular Surgery Program, Department of Surgery, Section of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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30
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Marziano C, Genet G, Hirschi KK. Vascular endothelial cell specification in health and disease. Angiogenesis 2021; 24:213-236. [PMID: 33844116 PMCID: PMC8205897 DOI: 10.1007/s10456-021-09785-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/17/2021] [Indexed: 02/08/2023]
Abstract
There are two vascular networks in mammals that coordinately function as the main supply and drainage systems of the body. The blood vasculature carries oxygen, nutrients, circulating cells, and soluble factors to and from every tissue. The lymphatic vasculature maintains interstitial fluid homeostasis, transports hematopoietic cells for immune surveillance, and absorbs fat from the gastrointestinal tract. These vascular systems consist of highly organized networks of specialized vessels including arteries, veins, capillaries, and lymphatic vessels that exhibit different structures and cellular composition enabling distinct functions. All vessels are composed of an inner layer of endothelial cells that are in direct contact with the circulating fluid; therefore, they are the first responders to circulating factors. However, endothelial cells are not homogenous; rather, they are a heterogenous population of specialized cells perfectly designed for the physiological demands of the vessel they constitute. This review provides an overview of the current knowledge of the specification of arterial, venous, capillary, and lymphatic endothelial cell identities during vascular development. We also discuss how the dysregulation of these processes can lead to vascular malformations, and therapeutic approaches that have been developed for their treatment.
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Affiliation(s)
- Corina Marziano
- Department of Cell Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.,Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Gael Genet
- Department of Cell Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.,Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Karen K Hirschi
- Department of Cell Biology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA. .,Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA. .,Department of Medicine, Yale Cardiovascular Research Center, Yale University School of Medicine, New Haven, CT, 06520, USA.
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31
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Retta SF, Perrelli A, Trabalzini L, Finetti F. From Genes and Mechanisms to Molecular-Targeted Therapies: The Long Climb to the Cure of Cerebral Cavernous Malformation (CCM) Disease. Methods Mol Biol 2021; 2152:3-25. [PMID: 32524540 DOI: 10.1007/978-1-0716-0640-7_1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cerebral cavernous malformation (CCM) is a rare cerebrovascular disorder of genetic origin consisting of closely clustered, abnormally dilated and leaky capillaries (CCM lesions), which occur predominantly in the central nervous system. CCM lesions can be single or multiple and may result in severe clinical symptoms, including focal neurological deficits, seizures, and intracerebral hemorrhage. Early human genetic studies demonstrated that CCM disease is linked to three chromosomal loci and can be inherited as autosomal dominant condition with incomplete penetrance and highly variable expressivity, eventually leading to the identification of three disease genes, CCM1/KRIT1, CCM2, and CCM3/PDCD10, which encode for structurally unrelated intracellular proteins that lack catalytic domains. Biochemical, molecular, and cellular studies then showed that these proteins are involved in endothelial cell-cell junction and blood-brain barrier stability maintenance through the regulation of major cellular structures and mechanisms, including endothelial cell-cell and cell-matrix adhesion, actin cytoskeleton dynamics, autophagy, and endothelial-to-mesenchymal transition, suggesting that they act as pleiotropic regulators of cellular homeostasis, and opening novel therapeutic perspectives. Indeed, accumulated evidence in cellular and animal models has eventually revealed that the emerged pleiotropic functions of CCM proteins are mainly due to their ability to modulate redox-sensitive pathways and mechanisms involved in adaptive responses to oxidative stress and inflammation, thus contributing to the preservation of cellular homeostasis and stress defenses.In this introductory review, we present a general overview of 20 years of amazing progress in the identification of genetic culprits and molecular mechanisms underlying CCM disease pathogenesis, and the development of targeted therapeutic strategies.
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Affiliation(s)
- Saverio Francesco Retta
- Department of Clinical and Biological Science, School of Medicine and Surgery, University of Torino, Orbassano (Torino), Italy. .,CCM Italia Research Network, Torino, Italy.
| | - Andrea Perrelli
- Department of Clinical and Biological Science, School of Medicine and Surgery, University of Torino, Orbassano (Torino), Italy.,CCM Italia Research Network, Torino, Italy
| | - Lorenza Trabalzini
- CCM Italia Research Network, Torino, Italy.,Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
| | - Federica Finetti
- CCM Italia Research Network, Torino, Italy.,Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
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Sartages M, Floridia E, García-Colomer M, Iglesias C, Macía M, Peñas P, Couraud PO, Romero IA, Weksler B, Pombo CM, Zalvide J. High Levels of Receptor Tyrosine Kinases in CCM3-Deficient Cells Increase Their Susceptibility to Tyrosine Kinase Inhibition. Biomedicines 2020; 8:E624. [PMID: 33348877 PMCID: PMC7766026 DOI: 10.3390/biomedicines8120624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/25/2022] Open
Abstract
Cerebral cavernous malformations (CCMs) are vascular malformations that can be the result of the deficiency of one of the CCM genes. Their only present treatment is surgical removal, which is not always possible, and an alternative pharmacological strategy to eliminate them is actively sought. We have studied the effect of the lack of one of the CCM genes, CCM3, in endothelial and non-endothelial cells. By comparing protein expression in control and CCM3-silenced cells, we found that the levels of the Epidermal Growth Factor Receptor (EGFR) are higher in CCM3-deficient cells, which adds to the known upregulation of Vascular Endothelial Growth Factor Receptor 2 (VEGFR2) in these cells. Whereas VEGFR2 is upregulated at the mRNA level, EGFR has a prolonged half-life. Inhibition of EGFR family members in CCM3-deficient cells does not revert the known cellular effects of lack of CCM genes, but it induces significantly more apoptosis in CCM3-deficient cells than in control cells. We propose that the susceptibility to tyrosine kinase inhibitors of CCM3-deficient cells can be harnessed to kill the abnormal cells of these lesions and thus treat CCMs pharmacologically.
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Affiliation(s)
- Miriam Sartages
- Department of Physiology, Centro Singular de Medicina Molecular e Enfermedades Crónicas (CiMUS), Instituto Sanitario de Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15703 Santiago de Compostela, Spain; (M.S.); (E.F.); (M.G.-C.); (C.I.); (C.M.P.)
| | - Ebel Floridia
- Department of Physiology, Centro Singular de Medicina Molecular e Enfermedades Crónicas (CiMUS), Instituto Sanitario de Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15703 Santiago de Compostela, Spain; (M.S.); (E.F.); (M.G.-C.); (C.I.); (C.M.P.)
- IQVIA RDS Ireland Limited, Eastpoint Business Park, Estuary House, Fairview, Dublin 3, D03 K7W7 Leinster, Ireland
| | - Mar García-Colomer
- Department of Physiology, Centro Singular de Medicina Molecular e Enfermedades Crónicas (CiMUS), Instituto Sanitario de Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15703 Santiago de Compostela, Spain; (M.S.); (E.F.); (M.G.-C.); (C.I.); (C.M.P.)
| | - Cristina Iglesias
- Department of Physiology, Centro Singular de Medicina Molecular e Enfermedades Crónicas (CiMUS), Instituto Sanitario de Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15703 Santiago de Compostela, Spain; (M.S.); (E.F.); (M.G.-C.); (C.I.); (C.M.P.)
| | - Manuel Macía
- Servicio de Obstetricia y Ginecología Hospital Clínico Universitario Santiago, 15703 Santiago de Compostela, Spain; (M.M.); (P.P.)
| | - Patricia Peñas
- Servicio de Obstetricia y Ginecología Hospital Clínico Universitario Santiago, 15703 Santiago de Compostela, Spain; (M.M.); (P.P.)
| | | | - Ignacio A. Romero
- Department of Life, Health and Chemical Sciences, The Open University, Milton Keynes MK7 6AA, UK;
| | - Babette Weksler
- Weill Medical College, Cornell University, 1300 York Ave, New York, NY 10065, USA;
| | - Celia M. Pombo
- Department of Physiology, Centro Singular de Medicina Molecular e Enfermedades Crónicas (CiMUS), Instituto Sanitario de Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15703 Santiago de Compostela, Spain; (M.S.); (E.F.); (M.G.-C.); (C.I.); (C.M.P.)
| | - Juan Zalvide
- Department of Physiology, Centro Singular de Medicina Molecular e Enfermedades Crónicas (CiMUS), Instituto Sanitario de Santiago de Compostela (IDIS), Universidade de Santiago de Compostela, 15703 Santiago de Compostela, Spain; (M.S.); (E.F.); (M.G.-C.); (C.I.); (C.M.P.)
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Flemming KD, Lanzino G. Cerebral Cavernous Malformation: What a Practicing Clinician Should Know. Mayo Clin Proc 2020; 95:2005-2020. [PMID: 32605781 DOI: 10.1016/j.mayocp.2019.11.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/17/2019] [Accepted: 11/13/2019] [Indexed: 01/24/2023]
Abstract
Cavernous malformations (CMs) are angiographically occult, low-flow vascular malformations of the central nervous system. They are acquired lesions, with approximately 80% of patients having the sporadic form and 20% the familial form of the disease. The lesions may also develop years after radiotherapy. At the microscopic level, they consist of endothelium-lined cavities (or "caverns") containing blood of different ages. The endothelium proliferates abnormally, and tight junctions are absent or dysfunctional, resulting in leakiness of the endothelium and clinical manifestations in some patients. Cavernous malformations can be an incidental finding or can present with focal neurologic deficits, seizures, or headache, with or without associated hemorrhage. Management of the CM lesion requires knowledge of the natural history of the disease compared with the risk of surgical intervention. Surgery is often considered for symptomatic patients with lesions in a noneloquent location. Medical management is warranted for symptoms related to the CM. Research aimed at understanding the genes and signaling pathways related to CMs have provided potential drug targets, and clinical trials are underway to determine whether medications reduce the risk of future bleeding without surgery or modify the disease course. In addition, recent epidemiologic data have aided practitioners in determining how to treat comorbid conditions in patients with a potentially hemorrhagic lesion. This review provides an overview of the epidemiology, presentation, and clinical management of CMs.
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Detter MR, Shenkar R, Benavides CR, Neilson CA, Moore T, Lightle R, Hobson N, Shen L, Cao Y, Girard R, Zhang D, Griffin E, Gallione CJ, Awad IA, Marchuk DA. Novel Murine Models of Cerebral Cavernous Malformations. Angiogenesis 2020; 23:651-666. [PMID: 32710309 DOI: 10.1007/s10456-020-09736-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 07/06/2020] [Indexed: 12/21/2022]
Abstract
Cerebral cavernous malformations (CCMs) are ectatic capillary-venous malformations that develop in approximately 0.5% of the population. Patients with CCMs may develop headaches, focal neurologic deficits, seizures, and hemorrhages. While symptomatic CCMs, depending upon the anatomic location, can be surgically removed, there is currently no pharmaceutical therapy to treat CCMs. Several mouse models have been developed to better understand CCM pathogenesis and test therapeutics. The most common mouse models induce a large CCM burden that is anatomically restricted to the cerebellum and contributes to lethality in the early days of life. These inducible models thus have a relatively short period for drug administration. We developed an inducible CCM3 mouse model that develops CCMs after weaning and provides a longer period for potential therapeutic intervention. Using this new model, three recently proposed CCM therapies, fasudil, tempol, vitamin D3, and a combination of the three drugs, failed to substantially reduce CCM formation when treatment was administered for 5 weeks, from postnatal day 21 (P21) to P56. We next restricted Ccm3 deletion to the brain vasculature and provided greater time (121 days) for CCMs to develop chronic hemorrhage, recapitulating the human lesions. We also developed the first model of acute CCM hemorrhage by injecting mice harboring CCMs with lipopolysaccharide. These efficient models will enable future drug studies to more precisely target clinically relevant features of CCM disease: CCM formation, chronic hemorrhage, and acute hemorrhage.
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Affiliation(s)
- Matthew R Detter
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Robert Shenkar
- Neurovascular Surgery Program, Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, 60637, USA
| | - Christian R Benavides
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Catherine A Neilson
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Thomas Moore
- Neurovascular Surgery Program, Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, 60637, USA
| | - Rhonda Lightle
- Neurovascular Surgery Program, Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, 60637, USA
| | - Nicholas Hobson
- Neurovascular Surgery Program, Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, 60637, USA
| | - Le Shen
- Neurovascular Surgery Program, Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, 60637, USA
| | - Ying Cao
- Neurovascular Surgery Program, Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, 60637, USA
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, 60637, USA
| | - Dongdong Zhang
- Neurovascular Surgery Program, Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, 60637, USA
| | - Erin Griffin
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Carol J Gallione
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Issam A Awad
- Neurovascular Surgery Program, Department of Neurosurgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, 60637, USA
| | - Douglas A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, 27705, USA. .,James B Duke Professor, Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Box 3175, Durham, NC, 27710, USA.
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Li J, Zhao Y, Choi J, Ting KK, Coleman P, Chen J, Cogger VC, Wan L, Shi Z, Moller T, Zheng X, Vadas MA, Gamble JR. Targeting miR-27a/VE-cadherin interactions rescues cerebral cavernous malformations in mice. PLoS Biol 2020; 18:e3000734. [PMID: 32502201 PMCID: PMC7299406 DOI: 10.1371/journal.pbio.3000734] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/17/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
Cerebral cavernous malformations (CCMs) are vascular lesions predominantly developing in the central nervous system (CNS), with no effective treatments other than surgery. Loss-of-function mutation in CCM1/krev interaction trapped 1 (KRIT1), CCM2, or CCM3/programmed cell death 10 (PDCD10) causes lesions that are characterized by abnormal vascular integrity. Vascular endothelial cadherin (VE-cadherin), a major regulator of endothelial cell (EC) junctional integrity is strongly disorganized in ECs lining the CCM lesions. We report here that microRNA-27a (miR-27a), a negative regulator of VE-cadherin, is elevated in ECs isolated from mouse brains developing early CCM lesions and in cultured ECs with CCM1 or CCM2 depletion. Furthermore, we show miR-27a acts downstream of kruppel-like factor (KLF)2 and KLF4, two known key transcription factors involved in CCM lesion development. Using CD5-2 (a target site blocker [TSB]) to prevent the miR-27a/VE-cadherin mRNA interaction, we present a potential therapy to increase VE-cadherin expression and thus rescue the abnormal vascular integrity. In CCM1- or CCM2-depleted ECs, CD5-2 reduces monolayer permeability, and in Ccm1 heterozygous mice, it restores dermal vessel barrier function. In a neonatal mouse model of CCM disease, CD5-2 normalizes vasculature and reduces vascular leakage in the lesions, inhibits the development of large lesions, and significantly reduces the size of established lesions in the hindbrain. Furthermore, CD5-2 limits the accumulation of inflammatory cells in the lesion area. Our work has established that VE-cadherin is a potential therapeutic target for normalization of the vasculature and highlights that targeting miR-27a/VE-cadherin interaction by CD5-2 is a potential novel therapy for the devastating disease, CCM. Cerebral cavernous malformation (CCM) is a disease for which, hitherto, surgery has been the only option. This study shows that a potential therapeutic, CD5-2, inhibits lesion development and vascular leak in the brains of CCM neonatal mice by targeting the endothelial cell–specific adhesion molecule VE-cadherin and restoring the vascular integrity of CCM lesions.
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Affiliation(s)
- Jia Li
- Centre for the Endothelium, Vascular Biology Program, Centenary Institute, The University of Sydney, Sydney, Australia
- Department of Biomedical Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Yang Zhao
- Centre for the Endothelium, Vascular Biology Program, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Jaesung Choi
- Laboratory of Cardiovascular Signaling, Vascular Biology Program, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Ka Ka Ting
- Centre for the Endothelium, Vascular Biology Program, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Paul Coleman
- Centre for the Endothelium, Vascular Biology Program, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Jinbiao Chen
- Liver Injury and Cancer Program, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Victoria C. Cogger
- Aging and Alzheimers Institute and ANZAC Research Institute and Concord Hospital, Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Li Wan
- Centre for the Endothelium, Vascular Biology Program, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Zhongsong Shi
- Department of Neurosurgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | | | - Xiangjian Zheng
- Laboratory of Cardiovascular Signaling, Vascular Biology Program, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Mathew A. Vadas
- Centre for the Endothelium, Vascular Biology Program, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Jennifer R. Gamble
- Centre for the Endothelium, Vascular Biology Program, Centenary Institute, The University of Sydney, Sydney, Australia
- * E-mail:
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Role of aspirin and statin therapy in patients with cerebral cavernous malformations. J Clin Neurosci 2020; 78:246-251. [PMID: 32340842 DOI: 10.1016/j.jocn.2020.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/14/2020] [Accepted: 04/05/2020] [Indexed: 12/23/2022]
Abstract
Stagnant blood flow and organizing thrombus are intralesional components of patients with cerebral cavernous malformations (CCM). Stasis and inflammation are mechanisms of growth, lesional instability and acute hemorrhages with or w/o symptoms. We evaluate the association of pre-diagnostic aspirin and/or statin use with acute hemorrhages at diagnosis. Patients with a CCM diagnosis were identified and categorized according to their medications on admission into four groups (no therapy, statin, aspirin, combined). The primary outcome was an acute hemorrhage (with or w/o symptoms) at diagnosis reported in a standardized manner from the T2 weighted magnetic resonance image. A multivariate generalized linear mixed models (GLMM) was utilized to conduct per-lesion analysis. We identified 446 patients with 635 lesions. An acute hemorrhage at diagnosis was observed in 31% of the patients. There were 328 patients without statin or aspirin therapy, 34% of whom presented with acute hemorrhage. Of patients on aspirin therapy at diagnosis, 25% presented with hemorrhage. Of patients on statin therapy, 26% had a hemorrhage at diagnosis. Combined therapy in 44 patients demonstrated a lower proportion of patients with acute hemorrhages (7 patients, 16% incidence). A GLMM showed that patients in the combined therapy group to have significantly lower odds of having an acute hemorrhage at diagnosis compared to the reference group of no therapy (OR 0.24; 95% CI 0.09-0.59; P = 0.002). Patients with a CCM receiving therapy with both aspirin and statins were less likely to present at diagnosis with acute hemorrhage.
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Polster SP, Stadnik A, Akers AL, Cao Y, Christoforidis GA, Fam MD, Flemming KD, Girard R, Hobson N, Koenig JI, Koskimäki J, Lane K, Liao JK, Lee C, Lyne SB, McBee N, Morrison L, Piedad K, Shenkar R, Sorrentino M, Thompson RE, Whitehead KJ, Zeineddine HA, Hanley DF, Awad IA. Atorvastatin Treatment of Cavernous Angiomas with Symptomatic Hemorrhage Exploratory Proof of Concept (AT CASH EPOC) Trial. Neurosurgery 2020; 85:843-853. [PMID: 30476251 DOI: 10.1093/neuros/nyy539] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 10/15/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND More than a million Americans harbor a cerebral cavernous angioma (CA), and those who suffer a prior symptomatic hemorrhage have an exceptionally high rebleeding risk. Preclinical studies show that atorvastatin blunts CA lesion development and hemorrhage through inhibiting RhoA kinase (ROCK), suggesting it may confer a therapeutic benefit. OBJECTIVE To evaluate whether atorvastatin produces a difference compared to placebo in lesional iron deposition as assessed by quantitative susceptibility mapping (QSM) on magnetic resonance imaging in CAs that have demonstrated a symptomatic hemorrhage in the prior year. Secondary aims shall assess effects on vascular permeability, ROCK activity in peripheral leukocytes, signal effects on clinical outcomes, adverse events, and prespecified subgroups. METHODS The phase I/IIa placebo-controlled, double-blinded, single-site clinical trial aims to enroll 80 subjects randomized 1-1 to atorvastatin (starting dose 80 mg PO daily) or placebo. Dosing shall continue for 24-mo or until reaching a safety endpoint. EXPECTED OUTCOMES The trial is powered to detect an absolute difference of 20% in the mean percent change in lesional QSM per year (2-tailed, power 0.9, alpha 0.05). A decrease in QSM change would be a signal of potential benefit, and an increase would signal a safety concern with the drug. DISCUSSION With firm mechanistic rationale, rigorous preclinical discoveries, and biomarker validations, the trial shall explore a proof of concept effect of a widely used repurposed drug in stabilizing CAs after a symptomatic hemorrhage. This will be the first clinical trial of a drug aimed at altering rebleeding in CA.
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Affiliation(s)
- Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Gregory A Christoforidis
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | | | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Nicholas Hobson
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - James I Koenig
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - James K Liao
- Section of Cardiology, Department of Medicine, The University of Chicago Medical Center, Illinois
| | | | - Seán B Lyne
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Nichol McBee
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Leslie Morrison
- Department of Neurology, University of New Mexico, Albuquerque, New Mexico
| | - Kristina Piedad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Robert Shenkar
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Matthew Sorrentino
- Section of Cardiology, Department of Medicine, The University of Chicago Medical Center, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Kevin J Whitehead
- Department of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Hussein A Zeineddine
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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Polster SP, Cao Y, Carroll T, Flemming K, Girard R, Hanley D, Hobson N, Kim H, Koenig J, Koskimäki J, Lane K, Majersik JJ, McBee N, Morrison L, Shenkar R, Stadnik A, Thompson RE, Zabramski J, Zeineddine HA, Awad IA. Trial Readiness in Cavernous Angiomas With Symptomatic Hemorrhage (CASH). Neurosurgery 2020; 84:954-964. [PMID: 29660039 DOI: 10.1093/neuros/nyy108] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/06/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Brain cavernous angiomas with symptomatic hemorrhage (CASH) are uncommon but exact a heavy burden of neurological disability from recurrent bleeding, for which there is no proven therapy. Candidate drugs to stabilize the CASH lesion and prevent rebleeding will ultimately require testing of safety and efficacy in multisite clinical trials. Much progress has been made in understanding the epidemiology of CASH, and novel biomarkers have been linked to the biological mechanisms and clinical activity in lesions. Yet, the ability to enroll and risk-stratify CASH subjects has never been assessed prospectively at multiple sites. Biomarkers and other outcomes have not been evaluated for their sensitivity and reliability, nor have they been harmonized across sites. OBJECTIVE To address knowledge gaps and establish a research network as infrastructure for future clinical trials, through the Trial Readiness grant mechanism, funded by National Institute of Neurological Disorders and Stroke/National Institutes of Health. METHODS This project includes an observational cohort study to assess (1) the feasibility of screening, enrollment rates, baseline disease categorization, and follow-up of CASH using common data elements at multiple sites, (2) the reliability of imaging biomarkers including quantitative susceptibility mapping and permeability measures that have been shown to correlate with lesion activity, and (3) the rates of recurrent hemorrhage and change in functional status and biomarker measurements during prospective follow-up. EXPECTED OUTCOMES We propose a harmonized multisite assessment of enrollment rates of CASH, baseline features relevant to stratification in clinical trials, and follow-up assessments of functional outcomes in relation to clinical bleeds. We introduce novel biomarkers of vascular leak and hemorrhage, with firm mechanistic foundations, which have been linked to clinical disease activity. We shall test their reliability and validity at multiple sites, and assess their changes over time, with and without clinical rebleeds, hence their fitness as outcome instruments in clinical trials. DISCUSSION The timing cannot be more opportune, with therapeutic targets identified, exceptional collaboration among researchers and the patient community, along with several drugs ready to benefit from development of a path to clinical testing using this network in the next 5 years.
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Affiliation(s)
- Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Timothy Carroll
- Department of Diagnostic Radiology, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Kelly Flemming
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Nicholas Hobson
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesiology, University of California San Francisco, San Francisco, California
| | - James Koenig
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | | | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Leslie Morrison
- Department of Neurology, University of New Mexico, Albuquerque, New Mexico
| | - Robert Shenkar
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Joseph Zabramski
- Department of Neurological Surgery, The Barrow Neurological Institute, Phoenix, ArizonaAll except the first and final author are listed in alphabetic order
| | - Hussein A Zeineddine
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
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Cardoso C, Arnould M, De Luca C, Otten C, Abdelilah-Seyfried S, Heredia A, Leutenegger AL, Schwaninger M, Tournier-Lasserve E, Boulday G. Novel Chronic Mouse Model of Cerebral Cavernous Malformations. Stroke 2020; 51:1272-1278. [PMID: 31992178 DOI: 10.1161/strokeaha.119.027207] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background and Purpose- Cerebral cavernous malformations (CCMs) are vascular malformations of the brain that lead to cerebral hemorrhages. A pharmacological treatment is needed especially for patients with nonoperable deep-seated lesions. We and others obtained CCM mouse models that were useful for mechanistic studies and rapid trials testing the preventive effects of candidate drugs. The shortened lifespan of acute mouse models hampered evaluation of compounds that would not only prevent lesion appearance but also cure preexisting lesions. Indirubin-3'-monoxime previously demonstrated its efficacy to reverse the cardiac phenotype of ccm2m201 zebrafish mutants and to prevent lesion development in an acute CCM2 mouse model. In the present article, we developed and characterized a novel chronic CCM2 mouse model and evaluated the curative therapeutic effect of indirubin-3'-monoxime after CCM lesion development. Methods- The chronic mouse model was obtained by a postnatal induction of brain-endothelial-cell-specific ablation of the Ccm2 gene using the inducible Slco1c1-CreERT2 mouse line. Results- We obtained a fully penetrant novel CCM chronic mouse model without any obvious off-target phenotypes and compatible with long-term survival. By 3 months of age, CCM lesions ranging in size from small isolated lesions to multiple caverns developed throughout the brain. Lesion burden was quantified in animals from 1 week to 5 months of age. Clear signs of intracerebral hemorrhages were noticed in brain-endothelial-cell-specific ablation of the Ccm2 gene. In contrast with its preventive effect in the acute CCM2 mouse model, a 20 mg/kg indirubin-3'-monoxime treatment for 3 weeks in 3-month old animals neither had any beneficial effect on the lesion burden nor alleviated cerebral hemorrhages. Conclusions- The brain-endothelial-cell-specific ablation of the Ccm2 gene chronic model is a strongly improved disease model for the CCM community whose challenge today is to decipher which candidate drugs might have a curative effect on patients' preexisting lesions. Visual Overview- An online visual overview is available for this article.
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Affiliation(s)
- Cécile Cardoso
- From the Université de Paris, NeuroDiderot, Inserm, Paris, France (C.C., M.A., C.D.L., A.-L.L., E.T.-L., G.B.)
| | - Minh Arnould
- From the Université de Paris, NeuroDiderot, Inserm, Paris, France (C.C., M.A., C.D.L., A.-L.L., E.T.-L., G.B.)
| | - Coralie De Luca
- From the Université de Paris, NeuroDiderot, Inserm, Paris, France (C.C., M.A., C.D.L., A.-L.L., E.T.-L., G.B.)
| | - Cécile Otten
- Institute of Biochemistry and Biology, Potsdam University, Germany (C.O., S.A.-S.)
| | - Salim Abdelilah-Seyfried
- Institute of Biochemistry and Biology, Potsdam University, Germany (C.O., S.A.-S.).,Institute of Molecular Biology, Hannover Medical School, Carl-Neuberg Straße 1, Germany (S.A.-S.)
| | - Alonso Heredia
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore (A.H.)
| | - Anne-Louise Leutenegger
- From the Université de Paris, NeuroDiderot, Inserm, Paris, France (C.C., M.A., C.D.L., A.-L.L., E.T.-L., G.B.)
| | - Markus Schwaninger
- Institute for Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Germany (M.S.)
| | - Elisabeth Tournier-Lasserve
- From the Université de Paris, NeuroDiderot, Inserm, Paris, France (C.C., M.A., C.D.L., A.-L.L., E.T.-L., G.B.).,Service de Génétique, AP-HP, Hopital Lariboisière, Paris, France (E.T.-L.)
| | - Gwénola Boulday
- From the Université de Paris, NeuroDiderot, Inserm, Paris, France (C.C., M.A., C.D.L., A.-L.L., E.T.-L., G.B.)
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Cerebral Cavernous Malformation Proteins in Barrier Maintenance and Regulation. Int J Mol Sci 2020; 21:ijms21020675. [PMID: 31968585 PMCID: PMC7013531 DOI: 10.3390/ijms21020675] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 12/18/2022] Open
Abstract
Cerebral cavernous malformation (CCM) is a disease characterized by mulberry shaped clusters of dilated microvessels, primarily in the central nervous system. Such lesions can cause seizures, headaches, and stroke from brain bleeding. Loss-of-function germline and somatic mutations of a group of genes, called CCM genes, have been attributed to disease pathogenesis. In this review, we discuss the impact of CCM gene encoded proteins on cellular signaling, barrier function of endothelium and epithelium, and their contribution to CCM and potentially other diseases.
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Zafar A, Quadri SA, Farooqui M, Ikram A, Robinson M, Hart BL, Mabray MC, Vigil C, Tang AT, Kahn ML, Yonas H, Lawton MT, Kim H, Morrison L. Familial Cerebral Cavernous Malformations. Stroke 2020; 50:1294-1301. [PMID: 30909834 DOI: 10.1161/strokeaha.118.022314] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Atif Zafar
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Syed A Quadri
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.A.Q.)
| | - Mudassir Farooqui
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Asad Ikram
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Myranda Robinson
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Blaine L Hart
- Radiology (B.L.H., M.C.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Marc C Mabray
- Radiology (B.L.H., M.C.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | | | - Alan T Tang
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Perelman School of Medicine, Philadelphia (A.T.T., M.L.K.)
| | - Mark L Kahn
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Perelman School of Medicine, Philadelphia (A.T.T., M.L.K.)
| | - Howard Yonas
- Neurosurgery (H.Y.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (M.T.L.)
| | - Helen Kim
- Department of Anesthesia and Perioperative Care and Department of Epidemiology and Biostatistics, University of California San Francisco (H.K.)
| | - Leslie Morrison
- From the Departments of Neurology (A.Z., M.F., A.I., M.R., L.M.), University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque
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Manet S, Vannier D, Bouin AP, Lisowska J, Albiges-Rizo C, Faurobert E. Immunofluorescence of Cell-Cell and Cell-Extracellular Matrix Adhesive Defects in In Vitro Endothelial CCM Model: Juxtacrine Role of Mutant Extracellular Matrix on Wild-Type Endothelial Cells. Methods Mol Biol 2020; 2152:401-416. [PMID: 32524568 DOI: 10.1007/978-1-0716-0640-7_29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endothelial cells lining cerebral cavernous malformations (CCM) present strong adhesive and mechanical defects. Increased cell contractility is a driver to the onset and the expansion of the CCM lesions. 2D in vitro endothelial models have been developed from either endothelial cells isolated from ccm1-3 knock-out mice or CCM1-3-silenced primary endothelial cells. These in vitro models faithfully recapitulate the adhesive and contractile defects of the CCM-deficient endothelial cells such as increased cell-extracellular matrix (ECM) adhesion through β1 integrin-anchored actin stress fibers, abnormal remodeling of the ECM, and destabilized VE-cadherin-dependent cell-cell junctions. Using such 2D in vitro CCM models, we have shown that the ECM remodeled by CCM-depleted endothelial cells can propagate CCM-like adhesive defects to wild-type endothelial cells, a process potentially pertinent to CCM lesion expansion. Here, we detail methods for studying the morphology of focal adhesions, actomyosin cytoskeleton, and VE-cadherin-dependent Adherens junctions by immunofluorescence and morphometric analyses. Moreover, we detail the protocols to produce and purify remodeled ECM and to test its effect on endothelial cell adhesion.
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Affiliation(s)
- Sandra Manet
- Institute for Advanced Biosciences, University Grenoble Alpes, INSERM U1209, CNRS UMR5309, Grenoble, France
| | - Daphné Vannier
- Institute for Advanced Biosciences, University Grenoble Alpes, INSERM U1209, CNRS UMR5309, Grenoble, France
| | - Anne-Pascale Bouin
- Institute for Advanced Biosciences, University Grenoble Alpes, INSERM U1209, CNRS UMR5309, Grenoble, France
| | - Justyna Lisowska
- Institute for Advanced Biosciences, University Grenoble Alpes, INSERM U1209, CNRS UMR5309, Grenoble, France
| | - Corinne Albiges-Rizo
- Institute for Advanced Biosciences, University Grenoble Alpes, INSERM U1209, CNRS UMR5309, Grenoble, France
| | - Eva Faurobert
- Institute for Advanced Biosciences, University Grenoble Alpes, INSERM U1209, CNRS UMR5309, Grenoble, France.
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Lant B, Pal S, Chapman EM, Yu B, Witvliet D, Choi S, Zhao L, Albiges-Rizo C, Faurobert E, Derry WB. Interrogating the ccm-3 Gene Network. Cell Rep 2019; 24:2857-2868.e4. [PMID: 30208312 DOI: 10.1016/j.celrep.2018.08.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/27/2018] [Accepted: 08/15/2018] [Indexed: 01/29/2023] Open
Abstract
Cerebral cavernous malformations (CCMs) are neurovascular lesions caused by mutations in one of three genes (CCM1-3). Loss of CCM3 causes the poorest prognosis, and little is known about how it regulates vascular integrity. The C. elegans ccm-3 gene regulates the development of biological tubes that resemble mammalian vasculature, and in a genome-wide reverse genetic screen, we identified more than 500 possible CCM-3 pathway genes. With a phenolog-like approach, we generated a human CCM signaling network and identified 29 genes in common, of which 14 are required for excretory canal extension and membrane integrity, similar to ccm-3. Notably, depletion of the MO25 ortholog mop-25.2 causes severe defects in tube integrity by preventing CCM-3 localization to apical membranes. Furthermore, loss of MO25 phenocopies CCM3 ablation by causing stress fiber formation in endothelial cells. This work deepens our understanding of how CCM3 regulates vascular integrity and may help identify therapeutic targets for treating CCM3 patients.
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Affiliation(s)
- Benjamin Lant
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada
| | - Swati Pal
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada
| | - Eric Michael Chapman
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada; Department of Molecular Genetics, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada
| | - Bin Yu
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada
| | - Daniel Witvliet
- Department of Molecular Genetics, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada; Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, 600 University Avenue, Toronto, ON M5G 1X5, Canada
| | - Soo Choi
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada
| | - Lisa Zhao
- Department of Molecular Genetics, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada
| | - Corinne Albiges-Rizo
- Institute for Advanced Biosciences, CNRS UMR 5309, INSERM U1209, University Grenoble Alpes, Allée des Alpes, 38700 La Tronche, France
| | - Eva Faurobert
- Institute for Advanced Biosciences, CNRS UMR 5309, INSERM U1209, University Grenoble Alpes, Allée des Alpes, 38700 La Tronche, France
| | - W Brent Derry
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada; Department of Molecular Genetics, University of Toronto, 1 King's College Circle, Toronto, ON M5S 1A8, Canada.
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44
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Tang AT, Sullivan KR, Hong CC, Goddard LM, Mahadevan A, Ren A, Pardo H, Peiper A, Griffin E, Tanes C, Mattei LM, Yang J, Li L, Mericko-Ishizuka P, Shen L, Hobson N, Girard R, Lightle R, Moore T, Shenkar R, Polster SP, Rödel CJ, Li N, Zhu Q, Whitehead KJ, Zheng X, Akers A, Morrison L, Kim H, Bittinger K, Lengner CJ, Schwaninger M, Velcich A, Augenlicht L, Abdelilah-Seyfried S, Min W, Marchuk DA, Awad IA, Kahn ML. Distinct cellular roles for PDCD10 define a gut-brain axis in cerebral cavernous malformation. Sci Transl Med 2019; 11:eaaw3521. [PMID: 31776290 PMCID: PMC6937779 DOI: 10.1126/scitranslmed.aaw3521] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 07/17/2019] [Accepted: 10/09/2019] [Indexed: 12/11/2022]
Abstract
Cerebral cavernous malformation (CCM) is a genetic, cerebrovascular disease. Familial CCM is caused by genetic mutations in KRIT1, CCM2, or PDCD10 Disease onset is earlier and more severe in individuals with PDCD10 mutations. Recent studies have shown that lesions arise from excess mitogen-activated protein kinase kinase kinase 3 (MEKK3) signaling downstream of Toll-like receptor 4 (TLR4) stimulation by lipopolysaccharide derived from the gut microbiome. These findings suggest a gut-brain CCM disease axis but fail to define it or explain the poor prognosis of patients with PDCD10 mutations. Here, we demonstrate that the gut barrier is a primary determinant of CCM disease course, independent of microbiome configuration, that explains the increased severity of CCM disease associated with PDCD10 deficiency. Chemical disruption of the gut barrier with dextran sulfate sodium augments CCM formation in a mouse model, as does genetic loss of Pdcd10, but not Krit1, in gut epithelial cells. Loss of gut epithelial Pdcd10 results in disruption of the colonic mucosal barrier. Accordingly, loss of Mucin-2 or exposure to dietary emulsifiers that reduce the mucus barrier increases CCM burden analogous to loss of Pdcd10 in the gut epithelium. Last, we show that treatment with dexamethasone potently inhibits CCM formation in mice because of the combined effect of action at both brain endothelial cells and gut epithelial cells. These studies define a gut-brain disease axis in an experimental model of CCM in which a single gene is required for two critical components: gut epithelial function and brain endothelial signaling.
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Affiliation(s)
- Alan T Tang
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Katie R Sullivan
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Courtney C Hong
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Lauren M Goddard
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Aparna Mahadevan
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Aileen Ren
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Heidy Pardo
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Amy Peiper
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Erin Griffin
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Ceylan Tanes
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Lisa M Mattei
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jisheng Yang
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Li Li
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Patricia Mericko-Ishizuka
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Le Shen
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago School of Medicine and Biological Sciences, Chicago, IL 60637, USA
| | - Nicholas Hobson
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago School of Medicine and Biological Sciences, Chicago, IL 60637, USA
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago School of Medicine and Biological Sciences, Chicago, IL 60637, USA
| | - Rhonda Lightle
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago School of Medicine and Biological Sciences, Chicago, IL 60637, USA
| | - Thomas Moore
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago School of Medicine and Biological Sciences, Chicago, IL 60637, USA
| | - Robert Shenkar
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago School of Medicine and Biological Sciences, Chicago, IL 60637, USA
| | - Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago School of Medicine and Biological Sciences, Chicago, IL 60637, USA
| | - Claudia J Rödel
- Institute for Biochemistry and Biology, Department of Animal Physiology, Potsdam University, Karl-Liebknecht-Str. 24-25, Haus 26, 14476 Potsdam, Germany
| | - Ning Li
- Department of Biomedical Sciences, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Qin Zhu
- Graduate Group in Genomics and Computational Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kevin J Whitehead
- Division of Cardiovascular Medicine and the Program in Molecular Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Xiangjian Zheng
- Department of Pharmacology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin 300070, China
- Centenary Institute, Sydney Medical School, University of Sydney, Sydney, NSW 2050, Australia
| | - Amy Akers
- Angioma Alliance, Norfolk, VA 23517, USA
| | - Leslie Morrison
- Department of Neurology and Pediatrics, University of New Mexico, Albuquerque, NM 87106, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Kyle Bittinger
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Christopher J Lengner
- Department of Biomedical Sciences, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Cell and Developmental Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Institute for Regenerative Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Markus Schwaninger
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, 23562 Lübeck, Germany
| | - Anna Velcich
- Department of Cell Biology, Albert Einstein College of Medicine/Albert Einstein Cancer Center, NY 10461, USA
| | - Leonard Augenlicht
- Department of Cell Biology, Albert Einstein College of Medicine/Albert Einstein Cancer Center, NY 10461, USA
| | - Salim Abdelilah-Seyfried
- Institute for Biochemistry and Biology, Department of Animal Physiology, Potsdam University, Karl-Liebknecht-Str. 24-25, Haus 26, 14476 Potsdam, Germany
- Institute of Molecular Biology, Hannover Medical School, Carl-Neuberg Str. 1, D-30625 Hannover, Germany
| | - Wang Min
- Department of Pathology and the Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Douglas A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago School of Medicine and Biological Sciences, Chicago, IL 60637, USA
| | - Mark L Kahn
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
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Shenkar R, Peiper A, Pardo H, Moore T, Lightle R, Girard R, Hobson N, Polster SP, Koskimäki J, Zhang D, Lyne SB, Cao Y, Chaudagar K, Saadat L, Gallione C, Pytel P, Liao JK, Marchuk D, Awad IA. Rho Kinase Inhibition Blunts Lesion Development and Hemorrhage in Murine Models of Aggressive Pdcd10/Ccm3 Disease. Stroke 2019; 50:738-744. [PMID: 30744543 DOI: 10.1161/strokeaha.118.024058] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background and Purpose- Previously, murine models Krit1 +/- Msh2 -/ - and Ccm2 +/ - Trp53 -/ - showed a reduction or no effect on cerebral cavernous malformation (CCM) burden and favorable effects on lesional hemorrhage by the robust Rock (Rho-associated protein kinase) inhibitor fasudil and by simvastatin (a weak pleiotropic inhibitor of Rock). Herein, we concurrently investigated treatment of the more aggressive Pdcd10/Ccm3 model with fasudil, simvastatin, and higher dose atorvastatin to determined effectiveness of Rock inhibition. Methods- The murine models, Pdcd10 +/ - Trp53 -/ - and Pdcd10 +/ - Msh2 -/ -, were contemporaneously treated from weaning to 5 months of age with fasudil (100 mg/kg per day in drinking water, n=9), simvastatin (40 mg/kg per day in chow, n=11), atorvastatin (80 mg/kg per day in chow, n=10), or with placebo (n=16). We assessed CCM volume in mouse brains by microcomputed tomography. Lesion burden was calculated as lesion volume normalized to total brain volume. We analyzed chronic hemorrhage in CCM lesions by quantitative intensity of Perls staining in brain sections. Results- The Pdcd10 +/ - Trp53 -/ - /Msh2 -/ - models showed a mean CCM lesion burden per mouse reduction from 0.0091 in placebos to 0.0042 ( P=0.027) by fasudil, and to 0.0047 ( P=0.025) by atorvastatin treatment, but was not changed significantly by simvastatin. Hemorrhage intensity per brain was commensurately decreased by Rock inhibition. Conclusions- These results support the exploration of proof of concept effect of high-dose atorvastatin on human CCM disease for potential therapeutic testing.
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Affiliation(s)
- Robert Shenkar
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Amy Peiper
- Molecular Genetics and Microbiology Department, Duke University Medical Center, Durham, NC (A.P., H.P., C.G., D.M.)
| | - Heidy Pardo
- Molecular Genetics and Microbiology Department, Duke University Medical Center, Durham, NC (A.P., H.P., C.G., D.M.)
| | - Thomas Moore
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Rhonda Lightle
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Romuald Girard
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Nicholas Hobson
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Sean P Polster
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Janne Koskimäki
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Dongdong Zhang
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Seán B Lyne
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Ying Cao
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Kiranj Chaudagar
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Laleh Saadat
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
| | - Carol Gallione
- Molecular Genetics and Microbiology Department, Duke University Medical Center, Durham, NC (A.P., H.P., C.G., D.M.)
| | - Peter Pytel
- Department of Pathology (P.P.), Biological Sciences Division, University of Chicago, IL
| | - James K Liao
- Section of Cardiology (J.K.L.), Biological Sciences Division, University of Chicago, IL
| | - Douglas Marchuk
- Molecular Genetics and Microbiology Department, Duke University Medical Center, Durham, NC (A.P., H.P., C.G., D.M.)
| | - Issam A Awad
- From the Section of Neurosurgery (R.S., T.M., R.L., R.G., N.H., S.P.P., J.K., D.Z., S.B.L., Y.C., K.C., L.S., I.A.A.), Biological Sciences Division, University of Chicago, IL
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Effect of Simvastatin on Permeability in Cerebral Cavernous Malformation Type 1 Patients: Results from a Pilot Small Randomized Controlled Clinical Trial. Transl Stroke Res 2019; 11:319-321. [PMID: 31643041 DOI: 10.1007/s12975-019-00737-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
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Andjelkovic AV, Xiang J, Stamatovic SM, Hua Y, Xi G, Wang MM, Keep RF. Endothelial Targets in Stroke: Translating Animal Models to Human. Arterioscler Thromb Vasc Biol 2019; 39:2240-2247. [PMID: 31510792 DOI: 10.1161/atvbaha.119.312816] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cerebral ischemia (stroke) induces injury to the cerebral endothelium that may contribute to parenchymal injury and worsen outcome. This review focuses on current preclinical studies examining how to prevent ischemia-induced endothelial dysfunction. It particularly focuses on targets at the endothelium itself. Those include endothelial tight junctions, transcytosis, endothelial cell death, and adhesion molecule expression. It also examines how such studies are being translated to the clinic, especially as adjunct therapies for preventing intracerebral hemorrhage during reperfusion of the ischemic brain. Identification of endothelial targets may prove valuable in a search for combination therapies that would specifically protect different cell types in ischemia.
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Affiliation(s)
- Anuska V Andjelkovic
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI.,Pathology (A.V.A., S.M.S.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Jianming Xiang
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Svetlana M Stamatovic
- Pathology (A.V.A., S.M.S.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Ya Hua
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Guohua Xi
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Michael M Wang
- Neurology (M.M.W.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI.,Molecular and Integrative Physiology (M.M.W., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Richard F Keep
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI.,Molecular and Integrative Physiology (M.M.W., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
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48
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McKerracher L, Shenkar R, Abbinanti M, Cao Y, Peiper A, Liao JK, Lightle R, Moore T, Hobson N, Gallione C, Ruschel J, Koskimäki J, Girard R, Rosen K, Marchuk DA, Awad IA. A Brain-Targeted Orally Available ROCK2 Inhibitor Benefits Mild and Aggressive Cavernous Angioma Disease. Transl Stroke Res 2019; 11:365-376. [PMID: 31446620 DOI: 10.1007/s12975-019-00725-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/01/2019] [Accepted: 08/13/2019] [Indexed: 12/01/2022]
Abstract
Cavernous angioma (CA) is a vascular pathology caused by loss of function in one of the 3 CA genes (CCM1, CCM2, and CCM3) that result in rho kinase (ROCK) activation. We investigated a novel ROCK2 selective inhibitor for the ability to reduce brain lesion formation, growth, and maturation. We used genetic methods to explore the use of a ROCK2-selective kinase inhibitor to reduce growth and hemorrhage of CAs. The role of ROCK2 in CA was investigated by crossing Rock1 or Rock2 hemizygous mice with Ccm1 or Ccm3 hemizygous mice, and we found reduced lesions in the Rock2 hemizygous mice. A ROCK2-selective inhibitor, BA-1049 was used to investigate efficacy in reducing CA lesions after oral administration to Ccm1+/- and Ccm3+/- mice that were bred into a mutator background. After assessing the dose range effective to target brain endothelial cells in an ischemic brain model, Ccm1+/- and Ccm3+/- transgenic mice were treated for 3 (Ccm3+/-) or 4 months (Ccm1+/-), concurrently, randomized to receive one of three doses of BA-1049 in drinking water, or placebo. Lesion volumes were assessed by micro-computed tomography. BA-1049 reduced activation of ROCK2 in Ccm3+/-Trp53-/- lesions. Ccm1+/-Msh2-/- (n=68) and Ccm3+/-Trp53-/- (n=71) mice treated with BA-1049 or placebo showed a significant dose-dependent reduction in lesion volume after treatment with BA-1049, and a reduction in hemorrhage (iron deposition) near lesions at all doses. These translational studies show that BA-1049 is a promising therapeutic agent for the treatment of CA, a disease with no current treatment except surgical removal of the brain lesions.
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Affiliation(s)
- Lisa McKerracher
- BioAxone BioSciences Inc., Cambridge, MA, USA.,Department of Neurology and Neurosurgery, McGill University, Montreal, Canada
| | - Robert Shenkar
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | | | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Amy Peiper
- Department of Molecular Genetics and Microbiology, Duke University, Durham, NC, USA
| | - James K Liao
- Section of Cardiology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Rhonda Lightle
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Thomas Moore
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Nicholas Hobson
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Carol Gallione
- Department of Molecular Genetics and Microbiology, Duke University, Durham, NC, USA
| | | | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | | | - Douglas A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University, Durham, NC, USA
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA.
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49
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Koskimäki J, Zhang D, Li Y, Saadat L, Moore T, Lightle R, Polster SP, Carrión-Penagos J, Lyne SB, Zeineddine HA, Shi C, Shenkar R, Romanos S, Avner K, Srinath A, Shen L, Detter MR, Snellings D, Cao Y, Lopez-Ramirez MA, Fonseca G, Tang AT, Faber P, Andrade J, Ginsberg M, Kahn ML, Marchuk DA, Girard R, Awad IA. Transcriptome clarifies mechanisms of lesion genesis versus progression in models of Ccm3 cerebral cavernous malformations. Acta Neuropathol Commun 2019; 7:132. [PMID: 31426861 PMCID: PMC6699077 DOI: 10.1186/s40478-019-0789-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023] Open
Abstract
Cerebral cavernous malformations (CCMs) are dilated capillaries causing epilepsy and stroke. Inheritance of a heterozygous mutation in CCM3/PDCD10 is responsible for the most aggressive familial form of the disease. Here we studied the differences and commonalities between the transcriptomes of microdissected lesional neurovascular units (NVUs) from acute and chronic in vivo Ccm3/Pdcd10ECKO mice, and cultured brain microvascular endothelial cells (BMECs) Ccm3/Pdcd10ECKO.We identified 2409 differentially expressed genes (DEGs) in acute and 2962 in chronic in vivo NVUs compared to microdissected brain capillaries, as well as 121 in in vitro BMECs with and without Ccm3/Pdcd10 loss (fold change ≥ |2.0|; p < 0.05, false discovery rate corrected). A functional clustered dendrogram generated using the Euclidean distance showed that the DEGs identified only in acute in vivo NVUs were clustered in cellular proliferation gene ontology functions. The DEGs only identified in chronic in vivo NVUs were clustered in inflammation and immune response, permeability, and adhesion functions. In addition, 1225 DEGs were only identified in the in vivo NVUs but not in vitro BMECs, and these clustered within neuronal and glial functions. One miRNA mmu-miR-3472a was differentially expressed (FC = - 5.98; p = 0.07, FDR corrected) in the serum of Ccm3/Pdcd10+/- when compared to wild type mice, and this was functionally related as a putative target to Cand2 (cullin associated and neddylation dissociated 2), a DEG in acute and chronic lesional NVUs and in vitro BMECs. Our results suggest that the acute model is characterized by cell proliferation, while the chronic model showed inflammatory, adhesion and permeability processes. In addition, we highlight the importance of extra-endothelial structures in CCM disease, and potential role of circulating miRNAs as biomarkers of disease, interacting with DEGs. The extensive DEGs library of each model will serve as a validation tool for potential mechanistic, biomarker, and therapeutic targets.
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Affiliation(s)
- Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Dongdong Zhang
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Yan Li
- Center for Research Informatics, The University of Chicago, Chicago, IL, USA
| | - Laleh Saadat
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Thomas Moore
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Rhonda Lightle
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Julián Carrión-Penagos
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Seán B Lyne
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Hussein A Zeineddine
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Changbin Shi
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Robert Shenkar
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Kenneth Avner
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Le Shen
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Matthew R Detter
- The Molecular Genetics and Microbiology Department, Duke University Medical Center, Durham, NC, USA
| | - Daniel Snellings
- The Molecular Genetics and Microbiology Department, Duke University Medical Center, Durham, NC, USA
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | | | - Gregory Fonseca
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Alan T Tang
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Pieter Faber
- University of Chicago Genomics Facility, The University of Chicago, Chicago, IL, USA
| | - Jorge Andrade
- Center for Research Informatics, The University of Chicago, Chicago, IL, USA
| | - Mark Ginsberg
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Mark L Kahn
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas A Marchuk
- The Molecular Genetics and Microbiology Department, Duke University Medical Center, Durham, NC, USA
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
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50
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Awad IA, Polster SP. Cavernous angiomas: deconstructing a neurosurgical disease. J Neurosurg 2019; 131:1-13. [PMID: 31261134 PMCID: PMC6778695 DOI: 10.3171/2019.3.jns181724] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/15/2019] [Indexed: 01/08/2023]
Abstract
Cavernous angioma (CA) is also known as cavernoma, cavernous hemangioma, and cerebral cavernous malformation (CCM) (National Library of Medicine Medical Subject heading unique ID D006392). In its sporadic form, CA occurs as a solitary hemorrhagic vascular lesion or as clustered lesions associated with a developmental venous anomaly. In its autosomal dominant familial form (Online Mendelian Inheritance in Man #116860), CA is caused by a heterozygous germline loss-of-function mutation in one of three genes-CCM1/KRIT1, CCM2/Malcavernin, and CCM3/PDCD10-causing multifocal lesions throughout the brain and spinal cord.In this paper, the authors review the cardinal features of CA's disease pathology and clinical radiological features. They summarize key aspects of CA's natural history and broad elements of evidence-based management guidelines, including surgery. The authors also discuss evidence of similar genetic defects in sporadic and familial lesions, consequences of CCM gene loss in different tissues at various stages of development, and implications regarding the pathobiology of CAs.The concept of CA with symptomatic hemorrhage (CASH) is presented as well as its relevance to clinical care and research in the field. Pathobiological mechanisms related to CA include inflammation and immune-mediated processes, angiogenesis and vascular permeability, microbiome driven factors, and lesional anticoagulant domains. These mechanisms have motivated the development of imaging and plasma biomarkers of relevant disease behavior and promising therapeutic targets.The spectrum of discoveries about CA and their implications endorse CA as a paradigm for deconstructing a neurosurgical disease.
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