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Di Martino E, Rayasam A, Vexler ZS. Brain Maturation as a Fundamental Factor in Immune-Neurovascular Interactions in Stroke. Transl Stroke Res 2024; 15:69-86. [PMID: 36705821 PMCID: PMC10796425 DOI: 10.1007/s12975-022-01111-7] [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: 07/13/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 01/28/2023]
Abstract
Injuries in the developing brain cause significant long-term neurological deficits. Emerging clinical and preclinical data have demonstrated that the pathophysiology of neonatal and childhood stroke share similar mechanisms that regulate brain damage, but also have distinct molecular signatures and cellular pathways. The focus of this review is on two different diseases-neonatal and childhood stroke-with emphasis on similarities and distinctions identified thus far in rodent models of these diseases. This includes the susceptibility of distinct cell types to brain injury with particular emphasis on the role of resident and peripheral immune populations in modulating stroke outcome. Furthermore, we discuss some of the most recent and relevant findings in relation to the immune-neurovascular crosstalk and how the influence of inflammatory mediators is dependent on specific brain maturation stages. Finally, we comment on the current state of treatments geared toward inducing neuroprotection and promoting brain repair after injury and highlight that future prophylactic and therapeutic strategies for stroke should be age-specific and consider gender differences in order to achieve optimal translational success.
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Affiliation(s)
- Elena Di Martino
- Department of Neurology, University California San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158-0663, USA
| | - Aditya Rayasam
- Department of Neurology, University California San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158-0663, USA
| | - Zinaida S Vexler
- Department of Neurology, University California San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158-0663, USA.
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2
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Mallard C, Ferriero DM, Vexler ZS. Immune-Neurovascular Interactions in Experimental Perinatal and Childhood Arterial Ischemic Stroke. Stroke 2024; 55:506-518. [PMID: 38252757 DOI: 10.1161/strokeaha.123.043399] [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] [Indexed: 01/24/2024]
Abstract
Emerging clinical and preclinical data have demonstrated that the pathophysiology of arterial ischemic stroke in the adult, neonates, and children share similar mechanisms that regulate brain damage but also have distinct molecular signatures and involved cellular pathways due to the maturational stage of the central nervous system and the immune system at the time of the insult. In this review, we discuss similarities and differences identified thus far in rodent models of 2 different diseases-neonatal (perinatal) and childhood arterial ischemic stroke. In particular, we review acquired knowledge of the role of resident and peripheral immune populations in modulating outcomes in models of perinatal and childhood arterial ischemic stroke and the most recent and relevant findings in relation to the immune-neurovascular crosstalk, and how the influence of inflammatory mediators is dependent on specific brain maturation stages. Finally, we discuss the current state of treatments geared toward age-appropriate therapies that signal via the immune-neurovascular interaction and consider sex differences to achieve successful translation.
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Affiliation(s)
- Carina Mallard
- Department of Physiology, Institute of Neuroscience and Physiology, University of Gothenburg, Sweden (C.M.)
| | - Donna M Ferriero
- Department of Pediatrics, UCSF, San Francisco, CA (D.M.F.)
- Department of Neurology, UCSF, Weill Institute for Neurosciences, San Francisco, CA (D.M.F., Z.S.V.)
| | - Zinaida S Vexler
- Department of Neurology, UCSF, Weill Institute for Neurosciences, San Francisco, CA (D.M.F., Z.S.V.)
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3
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Sablić S, Dolić K, Kraljević I, Budimir Mršić D, Čičmir-Vestić M, Benzon B, Lovrić Kojundžić S, Marinović Guić M. The Presence of Communicating Arteries in the Circle of Willis Is Associated with Higher Rate of Functional Recovery after Anterior Circulation Ischemic Stroke. Biomedicines 2023; 11:3008. [PMID: 38002008 PMCID: PMC10669712 DOI: 10.3390/biomedicines11113008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/02/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Acute ischemic stroke (AIS) is the world's second leading cause of mortality. An established method for treating stroke patients in acute settings is endovascular therapy (EVT). However, the correlation of the successful endovascular treatment of AIS with the presence of communicating arteries in the circle of Willis needs to be proven. Our study examined clinical and radiological data of 158 consecutive patients treated with mechanical thrombectomy (MT) at our comprehensive stroke center. We analyzed their CT angiograms and digital subtraction angiography (DSA) to assess anatomical variants of Willis' circle and formed two groups-collateral-negative and collateral-positive group. The first group included patients with aplasia of both anterior (ACoA) and posterior communicating Artery (PCoA). The second group included patients that have at least one communicating artery (either anterior or posterior). We evaluated their reperfusion outcomes and functional recovery three months later. Our results showed that patients with communicating arteries had smaller areas of infarction on post-interventional CT and higher rates of functional recovery (Modified Rankin Score). The ACoA had a higher impact on early and late outcomes, confirmed by lower control CT scores and more favorable functional recovery. Therefore, anatomic variants of Willis' circle should be considered as a significant prognostic factor in AIS.
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Affiliation(s)
- Sara Sablić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.)
| | - Krešimir Dolić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.)
- University of Split School of Medicine, 21000 Split, Croatia
- University Department of Health Studies of the University of Split, 21000 Split, Croatia
| | - Ivan Kraljević
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.)
| | - Danijela Budimir Mršić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.)
- University of Split School of Medicine, 21000 Split, Croatia
- University Department of Health Studies of the University of Split, 21000 Split, Croatia
| | - Mate Čičmir-Vestić
- Department of Neurology, University Hospital of Split, 21000 Split, Croatia
| | - Benjamin Benzon
- University of Split School of Medicine, 21000 Split, Croatia
| | - Sanja Lovrić Kojundžić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.)
- University of Split School of Medicine, 21000 Split, Croatia
- University Department of Health Studies of the University of Split, 21000 Split, Croatia
| | - Maja Marinović Guić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.)
- University of Split School of Medicine, 21000 Split, Croatia
- University Department of Health Studies of the University of Split, 21000 Split, Croatia
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4
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Dastagir N, Obed D, Bucher F, Murad S, Dastagir K, Vogt PM. Blood Vessel Injuries of the Fingers: A Clinical Comparison of One- and Two-Arterial Blood Supply. J Clin Med 2023; 12:5889. [PMID: 37762830 PMCID: PMC10531927 DOI: 10.3390/jcm12185889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/19/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Traumatic finger injuries are very common in emergency medicine. When patients present with finger injuries, there is often damage to the vascular nerve bundles, which requires subsequent reconstruction. It is unknown if repairing a unilaterally injured artery affects patients' recovery in a well-perfused finger. This retrospective cohort study compares the clinical outcomes of 11 patients with one-vessel supply (mean age 48.3 years; 7 males, 4 females) to 14 patients with two-vessel supply (mean age 44.5 years; 8 males, 6 females). The patient outcomes were assessed using patient questionnaires (Disabilities of Arm, Shoulder, and Hand (DASH), European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L), and EuroQol visual analog scale (EQ-VAS)) and a clinical examination of hand function and imaging of circulatory efficiency. No significant changes were observed in the DASH, EQ-5D-5L, and EQ-VAS questionnaires. Clinical evaluation of hand function, measured by cold sensitivity, two-point discrimination, pain numerical analog scale, and grip strength also revealed no significant differences between cohorts. Blood flow measurements using thermal imaging revealed no effects on circulation in the affected digit. Collectively, the study finds reconstruction is not absolutely necessary when there is one intact digital artery as it is sufficient for healing and functional outcomes. We recommend finger artery reconstruction when both digital arteries are injured or if an immediate tension-free suture is possible.
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Affiliation(s)
- Nadjib Dastagir
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, 30625 Hannover, Germany; (D.O.); (F.B.); (S.M.); (K.D.); (P.M.V.)
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5
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Hu Y, Yang Z, Yan F, Huang S, Wang R, Han Z, Fan J, Zheng Y, Liu P, Luo Y, Li S. CCA repair or ECA ligation-Which middle cerebral artery occlusion is better in the reperfusion mouse model? IBRAIN 2023; 9:258-269. [PMID: 37786756 PMCID: PMC10527786 DOI: 10.1002/ibra.12128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 10/04/2023]
Abstract
A reliable animal model is essential for ischemic stroke research. The implications of the external carotid artery (ECA) transection or common carotid artery (CCA) ligation have been described. Thus, a modified animal model, the CCA-repair model, has been established, and studies have shown that the CCA-repair model has potential advantages over the CCA-ligation model. However, whether the CCA-repair model is superior to the ECA-ligation model remains unclear. Sixty male C57BL/6 mice were randomly assigned to establish the CCA-repair (n = 34) or ECA-ligation (n = 26) models. Cerebral blood flow before middle cerebral artery occlusion (MCAO), immediately after MCAO and reperfusion were monitored and the operation duration, postoperative body weight, and food intake within 7 days, and the number of intraoperative and postoperative deaths within 7 days were recorded in the two models. Modified neurological severity scores and Bederson (0-5) scores were used to evaluate postoperative neurological function deficits on Days 1/3/5/7. 2,3,5-Triphenyltetrazolium chloride staining was used to quantify lesion volume on Day 7 after the operation. We found the establishment of the CCA-repair model required a longer total operation duration (p = 0.0175), especially the operation duration of reperfusion (p < 0.0001). However, there was no significant difference in body weight and food intake development, lesion volume and intragroup variability, neurological function deficits, mortality, and survival probability between the two groups. The CCA-repair model has no significant advantage over the ECA-ligation model. The ECA-ligation model is still a better choice for focal cerebral ischemia.
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Affiliation(s)
- Yue Hu
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
| | - Zhen‐Hong Yang
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
| | - Feng Yan
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
| | - Shuang‐Feng Huang
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Rong‐Liang Wang
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
| | - Zi‐Ping Han
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
| | - Jun‐Fen Fan
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
| | - Yang‐Min Zheng
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
| | - Ping Liu
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
- Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain DisordersCapital Medical UniversityBeijingChina
| | - Yu‐Min Luo
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain DisordersCapital Medical UniversityBeijingChina
| | - Si‐Jie Li
- Department of Neurology, Institute of Cerebrovascular Disease ResearchXuanwu Hospital of Capital Medical UniversityBeijingChina
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain DisordersCapital Medical UniversityBeijingChina
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Mangiardi M, Bonura A, Iaccarino G, Alessiani M, Bravi MC, Crupi D, Pezzella FR, Fabiano S, Pampana E, Stilo F, Alfano G, Anticoli S. The Pathophysiology of Collateral Circulation in Acute Ischemic Stroke. Diagnostics (Basel) 2023; 13:2425. [PMID: 37510169 PMCID: PMC10378392 DOI: 10.3390/diagnostics13142425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/08/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Cerebral collateral circulation is a network of blood vessels which stabilizes blood flow and maintains cerebral perfusion whenever the main arteries fail to provide an adequate blood supply, as happens in ischemic stroke. These arterial networks are able to divert blood flow to hypoperfused cerebral areas. The extent of the collateral circulation determines the volume of the salvageable tissue, the so-called "penumbra". Clinically, this is associated with greater efficacy of reperfusion therapies (thrombolysis and thrombectomy) in terms of better short- and long-term functional outcomes, lower incidence of hemorrhagic transformation and of malignant oedema, and smaller cerebral infarctions. Recent advancements in brain imaging techniques (CT and MRI) allow us to study these anastomotic networks in detail and increase the likelihood of making effective therapeutic choices. In this narrative review we will investigate the pathophysiology, the clinical aspects, and the possible diagnostic and therapeutic role of collateral circulation in acute ischemic stroke.
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Affiliation(s)
- Marilena Mangiardi
- Department of Stroke Unit, San Camillo-Forlanini Hospital, 00152 Rome, Italy
| | - Adriano Bonura
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Gianmarco Iaccarino
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Michele Alessiani
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Maria Cristina Bravi
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Domenica Crupi
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Francesca Romana Pezzella
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Sebastiano Fabiano
- Department of Neuroradiology and Interventional Neuroradiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy
| | - Enrico Pampana
- Department of Neuroradiology and Interventional Neuroradiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy
| | - Francesco Stilo
- Unit of Vascular Surgery, Campus Bio-Medico University, 00128 Rome, Italy
| | - Guido Alfano
- Department of Radiology and Interventional Radiology, M.G. Vannini Hospital, 00177 Rome, Italy
| | - Sabrina Anticoli
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
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dos Santos Neto EP, de Sousa ÍA, Veras ADO, de Barros-Araújo ML, Ricarte IF, Pontes-Neto OM. Case report: Flow changes in routes of collateral circulation in patients with LVO and low NIHSS: a point favor to treat. Front Neurol 2023; 14:1165484. [PMID: 37360333 PMCID: PMC10287161 DOI: 10.3389/fneur.2023.1165484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/08/2023] [Indexed: 06/28/2023] Open
Abstract
The effectiveness of endovascular thrombectomy in patients presenting low National Institutes of Health Stroke Scale (NIHSS) scores remains controversial, and the acquisition of additional evidence is required to refine the selection of candidates who may benefit the most from this therapeutic modality. In this study, we present the case of a 62-year-old individual, with left internal carotid occlusion stroke and low NIHSS, who had compensatory collateral flow from Willis polygon via the anterior communicating artery. The patient subsequently exhibited neurological deterioration and collateral flow failure from Willis polygon, indicating the need for urgent intervention. The study of collaterals in patients with large vessel occlusion stroke has garnered considerable attention, with research suggesting that individuals with low NIHSS scores and poor collateral profiles may be at a heightened risk of early neurological deterioration. We postulate that such patients may derive significant benefits from endovascular thrombectomy, and may posit that an intensive transcranial Doppler monitoring protocol could facilitate the identification of suitable candidates for such intervention.
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Affiliation(s)
- Elizeu Pereira dos Santos Neto
- Institute of Radiology, University of São Paulo School of Medicine, Hospital das Clínicas, São Paulo, SP, Brazil
- Neurologist and Interventional Neuroradiologist, Hospital Santa Maria, Teresina, PI, Brazil
| | - Ícaro Araújo de Sousa
- Department of Neuroscience and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Arthur de Oliveira Veras
- Department of Neuroscience and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Marx Lima de Barros-Araújo
- Institute of Radiology, University of São Paulo School of Medicine, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Irapuá Ferreira Ricarte
- Department of Neurology and Neurosurgery, São Paulo Federal University, São Paulo, SP, Brazil
| | - Octávio Marques Pontes-Neto
- Department of Neuroscience and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
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Fox C. Pediatric Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:566-583. [PMID: 37039410 DOI: 10.1212/con.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Pediatric cerebrovascular disease is one of the leading causes of death and disability in children. Survivors of childhood stroke and their families are often left to cope with long-lasting sequelae, such as barriers to school reentry and long-term challenges in attaining independence as adults. Because childhood stroke is rare and providers may not be familiar with the disorder, this article reviews the risk factors, acute management, and sequelae of ischemic stroke in children. LATEST DEVELOPMENTS High-quality evidence has resulted in an organized approach to emergent treatment of ischemic stroke in adults, but most front-line providers are less prepared for emergent stroke management in children. The level of evidence for reperfusion therapies in children remains low but is growing. Thrombolysis and thrombectomy are sometimes considered for hyperacute treatment of stroke in children. Readiness for pediatric stroke at regional centers should include an organized approach to pediatric stroke triage and management based on extrapolation from adult stroke trials, expert consensus, and emerging pediatric studies. ESSENTIAL POINTS This review provides up-to-date information about ischemic stroke risk factors and management in children. Preparation for rapid stroke diagnosis and management in children may improve outcomes.
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Shen G, Sanchez K, Hu S, Zhao Z, Zhang L, Ma Q. 3D doppler ultrasound imaging of cerebral blood flow for assessment of neonatal hypoxic-ischemic brain injury in mice. PLoS One 2023; 18:e0285434. [PMID: 37159455 PMCID: PMC10168578 DOI: 10.1371/journal.pone.0285434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/21/2023] [Indexed: 05/11/2023] Open
Abstract
Cerebral blood flow (CBF) acutely reduces in neonatal hypoxic-ischemic encephalopathy (HIE). Clinic studies have reported that severe CBF impairment can predict HIE outcomes in neonates. Herein, the present study uses a non-invasive 3D ultrasound imaging approach to evaluate the changes of CBF after HI insult, and explores the correlation between CBF alterations and HI-induced brain infarct in mouse pups. The neonatal HI brain injury was induced in postnatal day 7 mouse pups using the Rice-Vannucci model. Non-invasive 3D ultrasound imaging was conducted to image CBF changes with multiple frequencies on mouse pups before common carotid artery (CCA) ligation, immediately after ligation, and 0 or 24 hours after HI. Vascularity ratio of the ipsilateral hemisphere was acutely reduced after unilateral ligation of the CCA alone or in combination with hypoxia, and partially restored at 24 hours after HI. Moreover, regression analysis showed that the vascularity ratio of ipsilateral hemisphere was moderately correlated with brain infarct size 24 hours after HI, indicating that CBF reduction contributes to of HI brain injury. To further verify the association between CBF and HI-induced brain injury, a neuropeptide C-type natriuretic peptide (CNP) or PBS was intranasally administrated to the brain of mouse pups one hour after HI insult. Brain infarction, CBF imaging and long-term neurobehavioral tests were conducted. The result showed that intranasal administration of CNP preserved ipsilateral CBF, reduced the infarct size, and improved neurological function after HI brain injury. Our findings suggest that CBF alteration is an indicator for neonatal HI brain injury, and 3D ultrasound imaging is a useful non-invasive approach for assessment of HI brain injury in mouse model.
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Affiliation(s)
- Guofang Shen
- Department of Basic Sciences, The Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
- Department of Hematologic Malignancies Translational Science, Beckman Research Institute of City of Hope, Duarte, CA, United States of America
| | - Kayla Sanchez
- Department of Basic Sciences, The Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Shirley Hu
- Department of Basic Sciences, The Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Zhen Zhao
- Zilkha Neurogenetic Institute and Department of Physiology and Neuroscience, Center for Neurodegeneration and Regeneration, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America
| | - Lubo Zhang
- Department of Basic Sciences, The Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Qingyi Ma
- Department of Basic Sciences, The Lawrence D. Longo, MD Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
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Kumar R, Sun LR, Rodriguez V, Sankar A, Sharma M, Meoded A, Brandão LR, Goldenberg NA. Hemostatic and Thrombotic Considerations in the Diagnosis and Management of Childhood Arterial Ischemic Stroke: A Narrative Review. Semin Pediatr Neurol 2022; 43:101003. [PMID: 36344025 DOI: 10.1016/j.spen.2022.101003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Although rare in children, arterial ischemic stroke (AIS) is associated with increased mortality and neurological morbidity. The incidence of AIS after the neonatal period is approximately 1-2/100,000/year, with an estimated mortality of 3-7%. A significant proportion of children surviving AIS experience life-long neurological deficits including hemiparesis, epilepsy, and cognitive delays. The low incidence of childhood AIS coupled with atypical clinical-presentation and lack of awareness contribute to delay in diagnosis and consequently, the early initiation of treatment. While randomized-clinical trials have demonstrated the efficacy and safety of reperfusion therapies including thrombolysis and endovascular thrombectomy in appropriately-selected adult patients, similar data for children are unavailable. Consequently, clinical decisions surrounding reperfusion therapy in childhood AIS are either extrapolated from adult data or based on local experience. The etiology of childhood AIS is multifactorial, often occurring in the setting of both acquired and congenital risk-factors including thrombophilia. While multiple studies have investigated the association of thrombophilia with incident childhood AIS, its impact on stroke recurrence and therefore duration and intensity of antithrombotic therapy is less clear. Despite these limitations, a significant progress has been made over the last decade in the management of childhood AIS. This progress can be attributed to international consortiums, and in selected cohorts to federally-funded clinical trials. In this narrative review, the authors have systematically appraised the literature and summarize the hemostatic and thrombotic considerations in the diagnosis and management of childhood AIS focusing on the evidence supporting reperfusion therapies, relevance of thrombophilia testing, and duration and drug choices for secondary-prophylaxis.
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Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD; Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Amanda Sankar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Mukta Sharma
- Division of Hematology, Children's Mercy Hospital, Kansas City, MO
| | - Avner Meoded
- Edward B. Singleton, Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON; Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Rescue of Mitochondrial SIRT3 Ameliorates Ischemia-like Injury in Human Endothelial Cells. Int J Mol Sci 2022; 23:ijms23169118. [PMID: 36012382 PMCID: PMC9409423 DOI: 10.3390/ijms23169118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/17/2022] Open
Abstract
Structural and functional alterations of vasculature caused by age-related factors is critically involved in the pathogenesis of ischemic stroke. The longevity genes sirtuins (SIRTs) are extensively investigated in aging-associated pathologies, but their distinct roles in ischemic stroke still remain to be clarified. To address this question, we applied oxygen and glucose deprived/reperfusion (OGD/R) to induce ischemic injury in human endothelial cells (ECs), which are the main component of vasculature in the brain. The results showed that OGD/R led to various damages to ECs, including compromised cell viability, increased LDH release, overproduced ROS, enhanced apoptosis and caspase activity. Meanwhile, the expression of mitochondrial SIRT3 was robustly decreased in ECs after OGD/R treatment. Consistently, rescue of SIRT3 by ectopic expression, but not nuclear SIRT1, in ECs reversed the OGD/R-induced cell damage. Interestingly, some front-line drugs for ischemic stroke, including clopidogrel, aspirin and dl-3-n-butylphthalide (NBP), also rescued SIRT3 and reduced OGD/R-induced endothelial injury, suggesting that the recovery of SIRT3 expression was critical for the protection of these drugs. Moreover, our results demonstrated that 10-hydroxy-NBP (OHNBP), a major metabolite of NBP, showed better blood-brain barrier crossing capability than NBP, but still retained the effects on SIRT3 by NBP. Together, our results suggested that SIRT3 may serve as a potential novel target for treatment of ischemic stroke.
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12
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Lagebrant C, Ramgren B, Hassani Espili A, Marañon A, Kremer C. Sex Differences in Collateral Circulation and Outcome After Mechanical Thrombectomy in Acute Ischemic Stroke. Front Neurol 2022; 13:878759. [PMID: 35665053 PMCID: PMC9160377 DOI: 10.3389/fneur.2022.878759] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Collateral circulation is known to lead to smaller infarct volume and better functional outcome after mechanical thrombectomy (MT), but studies examining sex differences in collateral circulation are scarce. The aim of this study was to investigate if collateral circulation has a different impact on outcome in women and men. Methods A single-center retrospective study of 487 patients (230 men and 257 women) treated with MT for acute ischemic stroke in the anterior cerebral circulation. Collateral circulation was assessed on computed tomography angiography images. The outcome was evaluated at 90 days according to the modified Rankin Scale (mRS). Results Women were older, median age 76 years (IQR 68-83) vs. 71 years (IQR 63–78). Stroke severity and time to recanalization were comparable. More women had moderate or good collaterals in 58.4 vs. 47.0% for men (p = 0.01). Among patients with moderate and good collaterals significantly more men (61%) were functionally independent (mRS 0–2) than women (41.5%) (p = < 0.01). This difference remained significant after correcting for age by linear weighting, 60.4 vs. 46.8% (p = 0.03). Conclusion Women had better collateral flow but showed worse functional outcomes, while good collateral flow led to better outcomes in men, even after correcting for age. Further clinical studies on peri- and post-interventional care, factors affecting recovery after hospital discharge as well as basic research on the neurovascular unit are needed to find modifiable targets to improve clinical outcomes for women.
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Affiliation(s)
| | - Birgitta Ramgren
- Department of Diagnostic Radiology, Neuroradiology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | | | | | - Christine Kremer
- Neurology Department, Department of Clinical Sciences, Skåne University Hospital Malmö, Lund University, Lund, Sweden
- *Correspondence: Christine Kremer
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13
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Hung SH, Kramer S, Werden E, Campbell BCV, Brodtmann A. Pre-stroke Physical Activity and Cerebral Collateral Circulation in Ischemic Stroke: A Potential Therapeutic Relationship? Front Neurol 2022; 13:804187. [PMID: 35242097 PMCID: PMC8886237 DOI: 10.3389/fneur.2022.804187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
Favorable cerebral collateral circulation contributes to hindering penumbral tissue from progressing to infarction and is associated with positive clinical outcomes after stroke. Given its clinical importance, improving cerebral collateral circulation is considered a therapeutic target to reduce burden after stroke. We provide a hypothesis-generating discussion on the potential association between pre-stroke physical activity and cerebral collateral circulation in ischemic stroke. The recruitment of cerebral collaterals in acute ischemic stroke may depend on anatomical variations, capacity of collateral vessels to vasodilate, and individual risk factors. Physical activity is associated with improved cerebral endothelial and vascular function related to vasodilation and angiogenic adaptations, and risk reduction in individual risk factors. More research is needed to understand association between cerebral collateral circulation and physical activity. A presentation of different methodological considerations for measuring cerebral collateral circulation and pre-stroke physical activity in the context of acute ischemic stroke is included. Opportunities for future research into cerebral collateral circulation, physical activity, and stroke recovery is presented.
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Affiliation(s)
- Stanley Hughwa Hung
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Sharon Kramer
- Centre for Quality and Patient Safety Research, Alfred Health Partnership, Melbourne, VIC, Australia.,Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - Emilio Werden
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia.,Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| | - Bruce C V Campbell
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia.,Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Amy Brodtmann
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia.,Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
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14
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Zhang SQ, Xiao J, Chen M, Zhou LQ, Shang K, Qin C, Tian DS. Sphingosine-1-Phosphate Signaling in Ischemic Stroke: From Bench to Bedside and Beyond. Front Cell Neurosci 2021; 15:781098. [PMID: 34916911 PMCID: PMC8669352 DOI: 10.3389/fncel.2021.781098] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/08/2021] [Indexed: 01/01/2023] Open
Abstract
Sphingosine-1-phosphate (S1P) signaling is being increasingly recognized as a strong modulator of immune cell migration and endothelial function. Fingolimod and other S1P modulators in ischemic stroke treatment have shown promise in emerging experimental models and small-scale clinical trials. In this article, we will review the current knowledge of the role of S1P signaling in brain ischemia from the aspects of inflammation and immune interventions, sustaining endothelial functions, regulation of blood-brain barrier integrity, and functional recovery. We will then discuss the current and future therapeutic perspectives of targeting S1P for the treatment of ischemic stroke. Mechanism studies would help to bridge the gap between preclinical studies and clinical practice. Future success of bench-to-bedside translation shall be based on in depth understanding of S1P signaling during stroke and on the ability to have a fine temporal and spatial regulation of the signal pathway.
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Affiliation(s)
- Shuo-Qi Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Xiao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Man Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Luo-Qi Zhou
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Shang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chuan Qin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dai-Shi Tian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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15
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Bonnin P, Kubis N, Charriaut-Marlangue C. Collateral Supply in Preclinical Cerebral Stroke Models. Transl Stroke Res 2021; 13:512-527. [PMID: 34797519 PMCID: PMC9232412 DOI: 10.1007/s12975-021-00969-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 02/01/2023]
Abstract
Enhancing the collateral blood supply during the acute phase of cerebral ischemia may limit both the extension of the core infarct, by rescuing the penumbra area, and the degree of disability. Many imaging techniques have been applied to rodents in preclinical studies, to evaluate the magnitude of collateral blood flow and the time course of responses during the early phase of ischemic stroke. The collateral supply follows several different routes at the base of the brain (the circle of Willis) and its surface (leptomeningeal or pial arteries), corresponding to the proximal and distal collateral pathways, respectively. In this review, we describe and illustrate the cerebral collateral systems and their modifications following pre-Willis or post-Willis occlusion in rodents. We also review the potential pharmaceutical agents for stimulating the collateral blood supply tested to date. The time taken to establish a collateral blood flow supply through the leptomeningeal anastomoses differs between young and adult animals and between different species and genetic backgrounds. Caution is required when transposing preclinical findings to humans, and clinical trials must be performed to check the added value of pharmacological agents for stimulating the collateral blood supply at appropriate time points. However, collateral recruitment appears to be a rapid, beneficial, endogenous mechanism that can be stimulated shortly after artery occlusion. It should be considered a treatment target for use in addition to recanalization strategies.
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Affiliation(s)
- Philippe Bonnin
- APHP, Physiologie Clinique - Explorations Fonctionnelles, Hôpital Lariboisiere, Université de Paris, 2 rue Ambroise Paré, F-75010, Paris, France. .,INSERM U1148, LVTS, Hôpital Bichat, Université de Paris, F-75018, Paris, France.
| | - Nathalie Kubis
- APHP, Physiologie Clinique - Explorations Fonctionnelles, Hôpital Lariboisiere, Université de Paris, 2 rue Ambroise Paré, F-75010, Paris, France.,INSERM U1148, LVTS, Hôpital Bichat, Université de Paris, F-75018, Paris, France
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16
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Wei ZZ, Chen D, Lee MJH, Zhao Y, Gu X, Yu SP, Wei L. DL-3-n-butylphthalide Increases Collateriogenesis and Functional Recovery after Focal Ischemic Stroke in Mice. Aging Dis 2021; 12:1835-1849. [PMID: 34631224 PMCID: PMC8460296 DOI: 10.14336/ad.2020.1226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/26/2020] [Indexed: 12/25/2022] Open
Abstract
Recent evidence indicates that collateral circulation is critical for the outcome of ischemic stroke. DL-3-n-butylphthalide (NBP), a synthesized compound based on an extract from seeds of celery Apium graveolens Linn, has been used as a therapeutic drug, showing multiple neuroprotective and regenerative activities. A potential effect of NBP on collateral arterial regulation is unknown. We examined the effects of NBP on arteriogenesis of collateral arteries in vitro and a mouse ischemic stroke model. In cultures of mouse iPS cell-derived vascular progenitors, NBP (10 μM) significantly increased α-smooth muscle actin (αSMA)/CD-31 co-labeled cells and the expression of newly formed vasculature marker PDGFRα. A sensorimotor cortex ischemia was induced in transgenic mice expressing αSMA-GFP that allowed direct observation of arterial vasculatures in brain regions. NBP (80 mg/kg) was intranasally delivered 1 hr after stroke and once daily for 14 days. To label proliferating cells, 5-Bromo-2’-deoxyuridine (BrdU, 50 mg/kg, i.p.) was administrated every day from 3 days after stroke. Western blotting of peri-infarct tissue detected increased expressions of VEGF, Ang-1 and reduced nNOS level in NBP-treated mice. The NBP treatment significantly increased αSMA/BrdU co-labeled cells, the diameter of ipsilateral collaterals, and arterial area in ischemic and peri-infarct regions examined 14 days after stroke. Examined 3 days after stroke, NBP prevented functional deficits in the cylinder test and corner test. The NBP treatment of 14 days improved the local cerebral blood flow (LCBF) and functional performance in multiple tests. Thus, NBP promotes collateriogenesis, short and long-term structural and functional improvements after ischemic stroke.
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Affiliation(s)
- Zheng Zachory Wei
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Dongdong Chen
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew Joong H Lee
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Yingying Zhao
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Xiaohuan Gu
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Shan Ping Yu
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ling Wei
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
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17
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Nitzsche A, Poittevin M, Benarab A, Bonnin P, Camerer E. [Endothelial sphingosine 1-phosphate signaling maintains perfusion of the cerebral cortex in ischemic stroke]. Med Sci (Paris) 2021; 37:709-711. [PMID: 34491177 DOI: 10.1051/medsci/2021103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anja Nitzsche
- Université de Paris, Paris-Centre de recherche cardiovasculaire (PARCC), Inserm U970, 56 rue Leblanc, 75015 Paris, France
| | - Marine Poittevin
- Université de Paris, Paris-Centre de recherche cardiovasculaire (PARCC), Inserm U970, 56 rue Leblanc, 75015 Paris, France. - Institut des vaisseaux et du sang, hôpital Lariboisière, 75010 Paris, France
| | - Ammar Benarab
- Université de Paris, Paris-Centre de recherche cardiovasculaire (PARCC), Inserm U970, 56 rue Leblanc, 75015 Paris, France
| | - Philippe Bonnin
- Université de Paris, Inserm U1148, hôpital Bichat, 75018 Paris, France. - Université de Paris, APHP, Physiologie clinique-explorations fonctionnelles, hôpital Lariboisière, 75010 Paris France
| | - Eric Camerer
- Université de Paris, Paris-Centre de recherche cardiovasculaire (PARCC), Inserm U970, 56 rue Leblanc, 75015 Paris, France
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18
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Poly(ADP-Ribose) Polymerase Inhibitor PJ34 Reduces Brain Damage after Stroke in the Neonatal Mouse Brain. Curr Issues Mol Biol 2021; 43:301-312. [PMID: 34200155 PMCID: PMC8929080 DOI: 10.3390/cimb43010025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022] Open
Abstract
The poly(ADP-ribose) polymerase inhibitor PJ34 has recently been reported to increase cerebral blood flow, via the endothelial NO synthase, in the naive mouse brain throughout life. We addressed here the benefits of PJ34 after neonatal ischemia on hemodynamics and components of the neurovascular unit including the blood-brain barrier (BBB), microglia, and astrocytes. Nine-day-old mice were subjected to permanent MCA occlusion (pMCAo), and treated with either PBS or PJ34 (10 mg/kg). Mean blood-flow velocities (mBFV) were measured in both internal carotid arteries (ICA) and basilar trunk (BT) using Doppler-ultrasonography. BBB opening was assessed through somatostatin-receptor type-2 internalization and immunohistochemistry at 24 and 48 h. Lesion areas were measured 8 days after ischemia. In PBS-treated mice, pMCAo involved a drop in mBFV in the left ICA (p < 0.001 vs. basal), whereas mBFV remained stable in both right ICA and BT. PJ34 prevented this drop in the left ICA (NS vs. basal) and increased mBFV in the right ICA (p = 0.0038 vs. basal). No modification was observed in the BT. In contrast to PBS, BBB disruption extent and astrocyte demise were reduced in PJ34 mice only in the rostral brain at 48 h and 8 days post-pMCAo, respectively. Accordingly, 8 days after pMCAo, affected areas were reduced in the rostral brain (Bregma +0.86 and +0.14 mm), whereas total tissue loss was not reduced after PJ34 (4.0 ± 3.1%) vs. PBS (5.8 ± 3.4%). These results show that PJ34 reduced BBB permeability, astrocyte demise, and tissue loss (particularly in the rostral territories), suggesting that collateral supply mainly proceeds from the anterior ICA’s branches in the ischemic neonatal mouse brain.
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19
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Nitzsche A, Poittevin M, Benarab A, Bonnin P, Faraco G, Uchida H, Favre J, Garcia-Bonilla L, Garcia MCL, Léger PL, Thérond P, Mathivet T, Autret G, Baudrie V, Couty L, Kono M, Chevallier A, Niazi H, Tharaux PL, Chun J, Schwab SR, Eichmann A, Tavitian B, Proia RL, Charriaut-Marlangue C, Sanchez T, Kubis N, Henrion D, Iadecola C, Hla T, Camerer E. Endothelial S1P 1 Signaling Counteracts Infarct Expansion in Ischemic Stroke. Circ Res 2021; 128:363-382. [PMID: 33301355 PMCID: PMC7874503 DOI: 10.1161/circresaha.120.316711] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
RATIONALE Cerebrovascular function is critical for brain health, and endogenous vascular protective pathways may provide therapeutic targets for neurological disorders. S1P (Sphingosine 1-phosphate) signaling coordinates vascular functions in other organs, and S1P1 (S1P receptor-1) modulators including fingolimod show promise for the treatment of ischemic and hemorrhagic stroke. However, S1P1 also coordinates lymphocyte trafficking, and lymphocytes are currently viewed as the principal therapeutic target for S1P1 modulation in stroke. OBJECTIVE To address roles and mechanisms of engagement of endothelial cell S1P1 in the naive and ischemic brain and its potential as a target for cerebrovascular therapy. METHODS AND RESULTS Using spatial modulation of S1P provision and signaling, we demonstrate a critical vascular protective role for endothelial S1P1 in the mouse brain. With an S1P1 signaling reporter, we reveal that abluminal polarization shields S1P1 from circulating endogenous and synthetic ligands after maturation of the blood-neural barrier, restricting homeostatic signaling to a subset of arteriolar endothelial cells. S1P1 signaling sustains hallmark endothelial functions in the naive brain and expands during ischemia by engagement of cell-autonomous S1P provision. Disrupting this pathway by endothelial cell-selective deficiency in S1P production, export, or the S1P1 receptor substantially exacerbates brain injury in permanent and transient models of ischemic stroke. By contrast, profound lymphopenia induced by loss of lymphocyte S1P1 provides modest protection only in the context of reperfusion. In the ischemic brain, endothelial cell S1P1 supports blood-brain barrier function, microvascular patency, and the rerouting of blood to hypoperfused brain tissue through collateral anastomoses. Boosting these functions by supplemental pharmacological engagement of the endothelial receptor pool with a blood-brain barrier penetrating S1P1-selective agonist can further reduce cortical infarct expansion in a therapeutically relevant time frame and independent of reperfusion. CONCLUSIONS This study provides genetic evidence to support a pivotal role for the endothelium in maintaining perfusion and microvascular patency in the ischemic penumbra that is coordinated by S1P signaling and can be harnessed for neuroprotection with blood-brain barrier-penetrating S1P1 agonists.
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MESH Headings
- Animals
- Blood-Brain Barrier/drug effects
- Blood-Brain Barrier/metabolism
- Blood-Brain Barrier/pathology
- Blood-Brain Barrier/physiopathology
- Cerebral Arteries/drug effects
- Cerebral Arteries/metabolism
- Cerebral Arteries/pathology
- Cerebral Arteries/physiopathology
- Cerebrovascular Circulation
- Disease Models, Animal
- Endothelial Cells/metabolism
- Endothelial Cells/pathology
- Female
- Infarction, Middle Cerebral Artery/metabolism
- Infarction, Middle Cerebral Artery/pathology
- Infarction, Middle Cerebral Artery/physiopathology
- Infarction, Middle Cerebral Artery/prevention & control
- Ischemic Attack, Transient/metabolism
- Ischemic Attack, Transient/pathology
- Ischemic Attack, Transient/physiopathology
- Ischemic Attack, Transient/prevention & control
- Ischemic Stroke/metabolism
- Ischemic Stroke/pathology
- Ischemic Stroke/physiopathology
- Ischemic Stroke/prevention & control
- Lysophospholipids/metabolism
- Male
- Mice, 129 Strain
- Mice, Inbred C57BL
- Mice, Knockout
- Microcirculation
- Neuroprotective Agents/pharmacology
- Signal Transduction
- Sphingosine/analogs & derivatives
- Sphingosine/metabolism
- Sphingosine-1-Phosphate Receptors/agonists
- Sphingosine-1-Phosphate Receptors/genetics
- Sphingosine-1-Phosphate Receptors/metabolism
- Vascular Patency
- Mice
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Affiliation(s)
- Anja Nitzsche
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
| | - Marine Poittevin
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
- Institut des Vaisseaux et du Sang, Hôpital Lariboisière
| | - Ammar Benarab
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
| | - Philippe Bonnin
- Université de Paris, INSERM U965 and Physiologie Clinique - Explorations-Fonctionnelles, AP-HP, Hôpital Lariboisière
| | - Giuseppe Faraco
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, Cornell University, New York
| | - Hiroki Uchida
- Center for Vascular Biology, Weill Cornell Medical College, Cornell University, New York
| | - Julie Favre
- MITOVASC Institute, CARFI Facility, CNRS UMR 6015, INSERM U1083, Angers University
| | - Lidia Garcia-Bonilla
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, Cornell University, New York
| | - Manuela C. L. Garcia
- MITOVASC Institute, CARFI Facility, CNRS UMR 6015, INSERM U1083, Angers University
| | - Pierre-Louis Léger
- Institut des Vaisseaux et du Sang, Hôpital Lariboisière
- INSERM U1141, Hôpital Robert Debré
| | - Patrice Thérond
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Biochimie, Hôpital de Bicêtre, Le Kremlin Bicêtre, France; Université Paris-Sud
- UFR de Pharmacie, EA 4529, Châtenay-Malabry, France
| | - Thomas Mathivet
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
| | - Gwennhael Autret
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
| | | | - Ludovic Couty
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
| | - Mari Kono
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Institutes of Health, Bethesda, MD, USA
| | - Aline Chevallier
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
| | - Hira Niazi
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
| | | | - Jerold Chun
- Neuroscience Drug Discovery, Sanford Burnham Prebys Medical Discovery Institute, La Jolla
| | - Susan R. Schwab
- Skirball Institute of Biomolecular Medicine, New York University School of Medicine, New York
| | - Anne Eichmann
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
| | | | - Richard L. Proia
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Institutes of Health, Bethesda, MD, USA
| | | | - Teresa Sanchez
- Center for Vascular Biology, Weill Cornell Medical College, Cornell University, New York
| | - Nathalie Kubis
- Université de Paris, INSERM U965 and Physiologie Clinique - Explorations-Fonctionnelles, AP-HP, Hôpital Lariboisière
- Université de Paris, INSERM U1148, Hôpital Bichat, Paris, France
| | - Daniel Henrion
- MITOVASC Institute, CARFI Facility, CNRS UMR 6015, INSERM U1083, Angers University
| | - Costantino Iadecola
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, Cornell University, New York
| | - Timothy Hla
- Vascular Biology Program, Boston Children's Hospital
| | - Eric Camerer
- Université de Paris, Paris Cardiovascular Research Centre, INSERM
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20
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Kannan A, Delgardo M, Pennington-FitzGerald W, Jiang EX, Christophe BR, Connolly ES. Pharmacological management of cerebral ischemia in the elderly. Expert Opin Pharmacother 2020; 22:897-906. [PMID: 33382005 DOI: 10.1080/14656566.2020.1856815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: For elderly adults in the United States, stroke is the fifth leading cause of death of which ischemic strokes comprise a vast majority. Optimal pharmacological management of elderly ischemic stroke patients involves both reperfusion and supportive care. Recent research into pharmacological management has focused on vascular, immunomodulatory, cytoprotective, and alternative agents, some of which have shown limited success in clinical trials. However, no treatments have been established as a reliable mode for management of cerebral ischemia for elderly adults beyond acute thrombolysis.Areas covered: The authors conducted a literature search for ischemic stroke management in the elderly and a search for human drug studies for managing ischemic stroke on clinicaltrials.gov. Here, they describe recent progress in the pharmacological management of cerebral ischemia in the elderly.Expert opinion: Many drug classes (antihypertensive, cytoprotective and immunomodulatory, and alternative agents) have been explored with limited success in managing ischemic stroke, though some have shown preventative benefits. We generally observed a broad gap in evidence on elderly patients from studies across all drug classes, necessitating further studies to gain an understanding of effective management of ischemic stroke in this large demographic of patients.
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Affiliation(s)
- Adithya Kannan
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Mychael Delgardo
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Enoch X Jiang
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Brandon R Christophe
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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21
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Kanoke A, Akamatsu Y, Nishijima Y, To E, Lee CC, Li Y, Wang RK, Tominaga T, Liu J. The impact of native leptomeningeal collateralization on rapid blood flow recruitment following ischemic stroke. J Cereb Blood Flow Metab 2020; 40:2165-2178. [PMID: 32669022 PMCID: PMC7585920 DOI: 10.1177/0271678x20941265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The leptomeningeal collateral status is an independent predictor of stroke outcome. By means of optical coherent tomography angiography to compare two mouse strains with different extent of native leptomeningeal collateralization, we determined the spatiotemporal dynamics of collateral flow and downstream hemodynamics following ischemic stroke. A robust recruitment of leptomeningeal collateral flow was detected immediately after middle cerebral artery (MCA) occlusion in C57BL/6 mice, with continued expansion over the course of seven days. In contrast, little collateral recruitment was seen in Balb/C mice during- and one day after MCAO, which coincided with a greater infarct size and worse functional outcome compared to C57BL/6, despite a slight improvement of cortical perfusion seven days after MCAO. Both strains of mice experienced a reduction of blood flow in the penetrating arterioles (PA) by more than 90% 30-min after dMCAO, although the decrease of PA flow was greater and the recovery was less in the Balb/C mice. Further, Balb/C mice also displayed a prolonged greater heterogeneity of capillary transit time after dMCAO in the MCA territory compared to C57BL/6 mice. Our data suggest that the extent of native leptomeningeal collaterals affects downstream hemodynamics with a long lasting impact in the microvascular bed after cortical stroke.
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Affiliation(s)
- Atsushi Kanoke
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA.,Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yosuke Akamatsu
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA.,Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuo Nishijima
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA.,Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Eric To
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA
| | - Chih C Lee
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA
| | - Yuandong Li
- Department of Bioengineering, College of Engineering and School of Medicine, University of Washington, Seattle, WA, USA
| | - Ruikang K Wang
- Department of Bioengineering, College of Engineering and School of Medicine, University of Washington, Seattle, WA, USA
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jialing Liu
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA
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22
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Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Felling R, Carpenter JL, Wernovsky G, McDougall CG, Gailloud P, Pearl MS. Mechanical Thrombectomy for Acute Ischemic Stroke: Considerations in Children. Stroke 2020; 51:3174-3181. [PMID: 32912096 DOI: 10.1161/strokeaha.120.029698] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of mechanical thrombectomy for the treatment of acute childhood arterial ischemic stroke with large vessel occlusion is increasing, with mounting evidence for its feasibility and safety. Despite this emerging evidence, clear guidelines for patient selection, thrombectomy technique, and postprocedure care do not exist for the pediatric population. Due to unique features of stroke in children, neurologists and interventionalists must consider differences in patient size, anatomy, collateral vessels, imaging parameters, and expected outcomes that may impact appropriate patient selection and timing criteria. In addition, different causes of stroke and comorbidities in children must be considered and may alter the safety and efficacy of thrombectomy. To optimize the success of endovascular intervention in children, a multidisciplinary team should take into account these nuanced considerations when determining patient eligibility, developing a procedural approach, and formulating a postprocedure neurological monitoring and therapeutic plan.
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Affiliation(s)
- Lisa R Sun
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Dana Harrar
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gerald Drocton
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Carlos Castillo-Pinto
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Ryan Felling
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Jessica L Carpenter
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gil Wernovsky
- Divisions of Cardiac Critical Care and Pediatric Cardiology, Children's National Hospital, Washington, DC. (G.W.)
| | - Cameron G McDougall
- Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, MD. (C.G.M.)
| | - Philippe Gailloud
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Monica S Pearl
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.).,Department of Radiology, Children's National Hospital, Washington, DC. (M.S.P.)
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23
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Cerebral Vasodilator Property of Poly(ADP-Ribose) Polymerase Inhibitor (PJ34) in the Neonatal and Adult Mouse Is Mediated by the Nitric Oxide Pathway. Int J Mol Sci 2020; 21:ijms21186569. [PMID: 32911782 PMCID: PMC7555622 DOI: 10.3390/ijms21186569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/28/2020] [Accepted: 09/04/2020] [Indexed: 12/29/2022] Open
Abstract
The poly(ADP-ribose) polymerase (PARP) inhibitor PJ34 has been reported to improve endothelial dysfunction in the peripheral system. We addressed the role of PJ34 on the vascular tone and vasoreactivity during development in the mouse brain. Blood flows were measured in the basilar trunk using ultrasonography. Cerebral vasoreactivity or vasodilation reserve was estimated as a percentage increase in mean blood flow velocities (mBFV) recorded under normoxia-hypercapnia in control and after PJ34 administration. Non-selective and selective eNOS and nNOS inhibitors were used to evaluate the role of NO-pathway into the hemodynamic effects of PJ34. PJ34 increased mBFVs from 15.8 ± 1.6 to 19.1 ± 1.9 cm/s (p = 0.0043) in neonatal, from 14.6 ± 1.4 to 16.1 ± 0.9 cm/s (p = 0.0049) in adult, and from 15.7 ± 1.7 to 17.5 ± 2.0 cm/s (p = 0.0024) in aged mice 48 h after administration. These PJ34 values were similar to those measured in age-matched control mice under normoxia-hypercapnia. This recruitment was mediated through the activation of constitutive NO synthases in both the neonatal (38.2 ± 6.7 nmol/min/mg protein) and adult (31.5 ± 4.4 nmol/min/mg protein) brain, as compared to age-matched control brain (6.9 ± 0.4 and 6.3 ± 0.7 nmol/min/mg protein), respectively. In addition, quite selective eNOS inhibitor was able to inhibit the recruitment. PJ34 by itself is able to increase cerebral blood flow through the NO-pathway activation at least over 48 h after a single administration.
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24
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Afarideh M, Zhang X, Ferguson CM, Glockner JF, Lerman A, Textor SC, Lerman LO. Peristenotic Collateral Circulation in Atherosclerotic Renovascular Disease: Association With Kidney Function and Response to Treatment. Hypertension 2020; 76:497-505. [PMID: 32507040 DOI: 10.1161/hypertensionaha.120.15057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The significance of peristenotic collateral circulation (PCC) development around a stenotic renal artery is unknown. We tested the hypothesis that PCC is linked to loss of kidney function and recovery potential in patients with atherosclerotic renovascular disease (ARVD). Thirty-four patients with ARVD were assigned to medical-therapy with or without revascularization based on clinical indications. The PCC was visualized using multidetector computed tomography and defined relative to segmental arteries in patients with essential hypertension. PCC number before and 3 months after treatment was correlated with various renal parameters. Thirty-four stenotic kidneys from 30 patients were analyzed. PCC number correlated inversely with kidney volume. ARVD-stenotic kidneys with baseline PCC (collateral ARVD [C-ARVD], n=13) associated with elevated 24-hour urine protein and stenotic kidney vein level of tumor necrosis factor-α, lower single-kidney volume and blood flow, and greater hypoxia than in stenotic kidneys with no PCC (no collateral ARVD [NC-ARVD], n=17). Revascularization (but not medical-therapy alone) improved stenotic kidney function and reduced inflammation in both NC-ARVD and C-ARVD. In C-ARVD, revascularization also increased stenotic kidney volume, blood flow, and oxygenation to levels comparable to NC-ARVD, and induced PCC regression. However, revascularization improved systolic blood pressure, plasma renin activity, and filtration fraction only in NC-ARVD. Therefore, patients with C-ARVD have greater kidney dysfunction, atrophy, hypoxia, and inflammation compared with patients with NC-ARVD, suggesting that PCC does not effectively protect the stenotic kidney in ARVD. Renal artery revascularization improved in C-ARVD stenotic kidney function, but not hypertension or renin-angiotensin system activation. These observations may help direct management of patients with ARVD.
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Affiliation(s)
| | | | | | - James F Glockner
- From the Division of Nephrology and Hypertension and the Departments of Radiology (J.F.G.), Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Cardiovascular Medicine (A.L.), Mayo Clinic, Rochester, MN
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25
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Bálint AR, Puskás T, Menyhárt Á, Kozák G, Szenti I, Kónya Z, Marek T, Bari F, Farkas E. Aging Impairs Cerebrovascular Reactivity at Preserved Resting Cerebral Arteriolar Tone and Vascular Density in the Laboratory Rat. Front Aging Neurosci 2019; 11:301. [PMID: 31780917 PMCID: PMC6856663 DOI: 10.3389/fnagi.2019.00301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/21/2019] [Indexed: 12/26/2022] Open
Abstract
The age-related (mal)adaptive modifications of the cerebral microvascular system have been implicated in cognitive impairment and worse outcomes after ischemic stroke. The magnitude of the hyperemic response to spreading depolarization (SD), a recognized principle of ischemic lesion development has also been found to be reduced by aging. Here, we set out to investigate whether the SD-coupled reactivity of the pial arterioles is subject to aging, and whether concomitant vascular rarefaction may contribute to the age-related insufficiency of the cerebral blood flow (CBF) response. CBF was assessed with laser-speckle contrast analysis (LASCA), and the tone adjustment of pial arterioles was followed with intrinsic optical signal (IOS) imaging at green light illumination through a closed cranial window created over the parietal cortex of isoflurane-anesthetized young (2 months old) and old (18 months old) male Sprague-Dawley rats. Global forebrain ischemia and later reperfusion were induced by the bilateral occlusion and later release of both common carotid arteries. SDs were elicited repeatedly with topical 1M KCl. Pial vascular density was measured in green IOS images of the brain surface, while the density and resting diameter of the cortical penetrating vasculature was estimated with micro-computed tomography of paraformaldehyde-fixed cortical samples. Whilst pial arteriolar dilation in response to SD or ischemia induction were found reduced in the old rat brain, the density and resting diameter of pial cortical vessels, and the degree of SD-related oligemia emerged as variables unaffected by age in our experiments. Spatial flow distribution analysis identified an age-related shift to a greater representation of higher flow ranges in the reperfused cortex. According to our data, impairment of functional arteriolar dilation, at preserved vascular density and resting vascular tone, may be implicated in the age-related deficit of the CBF response to SD, and possibly in the reduced efficacy of neurovascular coupling in the aging brain. SD has been recognized as a potent pathophysiological contributor to ischemic lesion expansion, in part because of the insufficiency of the associated CBF response. Therefore, the age-related impairment of cerebral vasoreactivity as shown here is suggested to contribute to the age-related acceleration of ischemic lesion development.
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Affiliation(s)
- Armand R. Bálint
- Department of Medical Physics and Informatics, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Tamás Puskás
- Department of Medical Physics and Informatics, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Ákos Menyhárt
- Department of Medical Physics and Informatics, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Gábor Kozák
- Department of Physiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Imre Szenti
- Department of Applied and Environmental Chemistry, Interdisciplinary Excellence Centre, University of Szeged, Szeged, Hungary
| | - Zoltán Kónya
- Department of Applied and Environmental Chemistry, Interdisciplinary Excellence Centre, University of Szeged, Szeged, Hungary
- MTA-SZTE Reaction Kinetics and Surface Chemistry Research Group, University of Szeged, Szeged, Hungary
| | - Tamás Marek
- Department of Medical Physics and Informatics, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Ferenc Bari
- Department of Medical Physics and Informatics, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Eszter Farkas
- Department of Medical Physics and Informatics, Faculty of Medicine, University of Szeged, Szeged, Hungary
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