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Kollikowski AM, Pham M, März AG, Feick J, Vogt ML, Xiong Y, Strinitz M, Vollmuth C, Essig F, Neugebauer H, Haeusler KG, Hametner C, Zimmermann L, Stoll G, Schuhmann MK. MMP-9 release into collateral blood vessels before endovascular thrombectomy to assess the risk of major intracerebral haemorrhages and poor outcome for acute ischaemic stroke: a proof-of-concept study. EBioMedicine 2024; 103:105095. [PMID: 38579365 PMCID: PMC11002809 DOI: 10.1016/j.ebiom.2024.105095] [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: 07/12/2023] [Revised: 03/17/2024] [Accepted: 03/17/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Matrix metalloproteinases (MMPs) are implied in blood-brain barrier degradation and haemorrhagic transformation following ischaemic stroke, but their local relevance in the hyperacute disease phase is unknown. We aimed to examine ultra-early MMP-9 and MMP-2 release into collateral blood vessels, and to assess its prognostic value before therapeutic recanalisation by endovascular thrombectomy (EVT). METHODS We report a cross-sectional proof-of-concept study including patients undergoing EVT for large-vessel ischaemic stroke at the University Hospital Würzburg, Germany. We obtained liquid biopsies from the collateral circulation before recanalisation, and systemic control samples. Laboratory workup included quantification of MMP-9 and MMP-2 plasma concentrations by cytometric bead array, immunohistochemical analyses of cellular MMP-9 and MMP-2 expression, and detection of proteolytic activity by gelatine zymography. The clinical impact of MMP concentrations was assessed by stratification according to intracranial haemorrhagic lesions on postinterventional computed tomography (Heidelberg Bleeding Classification, HBC) and early functional outcome (modified Rankin Scale, mRS). We used multivariable logistic regression, receiver-operating-characteristic (ROC) curves, and fixed-level estimates of test accuracy measures to study the prognostic value of MMP-9 concentrations. FINDINGS Between August 3, 2018, and September 16, 2021, 264 matched samples from 132 patients (86 [65.2%] women, 46 [34.8%] men, aged 40-94 years) were obtained. Median (interquartile range, IQR) MMP-9 (279.7 [IQR 126.4-569.6] vs 441 [IQR 223.4-731.5] ng/ml, p < 0.0001) but not MMP-2 concentrations were increased within collateral blood vessels. The median MMP-9 expression level of invading neutrophils was elevated (fluorescence intensity, arbitrary unit: 2276 [IQR 1007-5086] vs 3078 [IQR 1108-7963], p = 0.0018). Gelatine zymography experiments indicated the locally confined proteolytic activity of MMP-9 but not of MMP-2. Pretherapeutic MMP-9 release into stroke-affected brain regions predicted the degree of intracerebral haemorrhages and clinical stroke severity after recanalisation, and independently increased the odds of space-occupying parenchymal haematomas (HBC1c-3a) by 1.54 times, and the odds of severe disability or death (mRS ≥5 at hospital discharge) by 2.33 times per 1000 ng/ml increase. Excessive concentrations of MMP-9 indicated impending parenchymal haematomas and severe disability or death with high specificity. INTERPRETATION Measurement of MMP-9 within collateral blood vessels is feasible and identifies patients with stroke at risk of major intracerebral haemorrhages and poor outcome before therapeutic recanalisation by EVT, thereby providing evidence of the concept validity of ultra-early local stroke biomarkers. FUNDING This work was funded by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) and the Interdisciplinary Centre for Clinical Research (IZKF) at the University of Würzburg.
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Affiliation(s)
| | - Mirko Pham
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Alexander G März
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Jörn Feick
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany; Department of Radiology, University Hospital Würzburg, Würzburg, Germany.
| | - Marius L Vogt
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Yanyan Xiong
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Marc Strinitz
- Department of Neuroradiology, University Hospital Würzburg, Würzburg, Germany; Department of Neuroradiology, Rechts der Isar Hospital, Technical University Munich, Munich, Germany.
| | - Christoph Vollmuth
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | - Fabian Essig
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | | | - Christian Hametner
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | - Lena Zimmermann
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | - Guido Stoll
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany; Institute of Experimental Biomedicine, University Hospital Würzburg, Würzburg, Germany.
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Denorme F, Ajanel A, Campbell RA. Immunothrombosis in neurovascular disease. Res Pract Thromb Haemost 2024; 8:102298. [PMID: 38292352 PMCID: PMC10825058 DOI: 10.1016/j.rpth.2023.102298] [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: 10/06/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 02/01/2024] Open
Abstract
A State of the Art lecture titled "Immunothrombosis in Neurovascular Diseases" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. Despite significant clinical advancements in stroke therapy, stroke remains a prominent contributor to both mortality and disability worldwide. Brain injury resulting from an ischemic stroke is a dynamic process that unfolds over time. Initially, an infarct core forms due to the abrupt and substantial blockage of blood flow. In the subsequent hours to days, the surrounding tissue undergoes gradual deterioration, primarily driven by sustained hypoperfusion, programmed cell death, and inflammation. While anti-inflammatory strategies have proven highly effective in experimental models of stroke, their successful translation to clinical use has proven challenging. To overcome this translational hurdle, a better understanding of the distinct immune response driving ischemic stroke brain injury is needed. In this review article, we give an overview of current knowledge regarding the immune response in ischemic stroke and the contribution of immunothrombosis to this process. We discuss therapeutic approaches to overcome detrimental immunothrombosis in ischemic stroke and how these can be extrapolated to other neurovascular diseases, such as Alzheimer's disease and multiple sclerosis. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Frederik Denorme
- University of Utah Molecular Medicine Program, Salt Lake City, Utah, USA
- Division of Vascular Neurology, Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Abigail Ajanel
- University of Utah Molecular Medicine Program, Salt Lake City, Utah, USA
- Division of Microbiology and Pathology, Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Robert A. Campbell
- University of Utah Molecular Medicine Program, Salt Lake City, Utah, USA
- Division of Microbiology and Pathology, Department of Pathology, University of Utah, Salt Lake City, Utah, USA
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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Feick J, Pham M, März AG, Vogt ML, Strinitz M, Stoll G, Schuhmann MK, Kollikowski AM. Distinct Alterations in Oxygenation, Ion Composition and Acid-Base Balance in Cerebral Collaterals During Large-Vessel Occlusion Stroke. Clin Neuroradiol 2023; 33:973-984. [PMID: 37284875 PMCID: PMC10654170 DOI: 10.1007/s00062-023-01296-w] [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: 12/20/2022] [Accepted: 04/24/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE Disturbances of blood gas and ion homeostasis including regional hypoxia and massive sodium (Na+)/potassium (K+) shifts are a hallmark of experimental cerebral ischemia but have not been sufficiently investigated for their relevance in stroke patients. METHODS We report a prospective observational study on 366 stroke patients who underwent endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) of the anterior circulation (18 December 2018-31 August 2020). Intraprocedural blood gas samples (1 ml) from within cerebral collateral arteries (ischemic) and matched systemic control samples were obtained according to a prespecified protocol in 51 patients. RESULTS We observed a significant reduction in cerebral oxygen partial pressure (-4.29%, paO2ischemic = 185.3 mm Hg vs. paO2systemic = 193.6 mm Hg; p = 0.035) and K+ concentrations (-5.49%, K+ischemic = 3.44 mmol/L vs. K+systemic = 3.64 mmol/L; p = 0.0083). The cerebral Na+:K+ ratio was significantly increased and negatively correlated with baseline tissue integrity (r = -0.32, p = 0.031). Correspondingly, cerebral Na+ concentrations were most strongly correlated with infarct progression after recanalization (r = 0.42, p = 0.0033). We found more alkaline cerebral pH values (+0.14%, pHischemic = 7.38 vs. pHsystemic = 7.37; p = 0.0019), with a time-dependent shift towards more acidotic conditions (r = -0.36, p = 0.055). CONCLUSION These findings suggest that stroke-induced changes in oxygen supply, ion composition and acid-base balance occur and dynamically progress within penumbral areas during human cerebral ischemia and are related to acute tissue damage.
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Affiliation(s)
- Jörn Feick
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Mirko Pham
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Alexander G März
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Marius L Vogt
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Marc Strinitz
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Guido Stoll
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | | | - Alexander M Kollikowski
- Department of Neuroradiology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
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Schuhmann MK, Langhauser F, Zimmermann L, Bellut M, Kleinschnitz C, Fluri F. Dimethyl Fumarate Attenuates Lymphocyte Infiltration and Reduces Infarct Size in Experimental Stroke. Int J Mol Sci 2023; 24:15540. [PMID: 37958527 PMCID: PMC10648192 DOI: 10.3390/ijms242115540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Ischemic stroke is associated with exacerbated tissue damage caused by the activation of immune cells and the initiation of other inflammatory processes. Dimethyl fumarate (DMF) is known to modulate the immune response, activate antioxidative pathways, and improve the blood-brain barrier (BBB) after stroke. However, the specific impact of DMF on immune cells after cerebral ischemia remains unclear. In our study, male mice underwent transient middle cerebral artery occlusion (tMCAO) for 30 min and received oral DMF (15 mg/kg) or a vehicle immediately after tMCAO, followed by twice-daily administrations for 7 days. Infarct volume was assessed on T2-weighted magnetic resonance images on days 1 and 7 after tMCAO. Brain-infiltrating immune cells (lymphocytes, monocytes) and microglia were quantified using fluorescence-activated cell sorting. DMF treatment significantly reduced infarct volumes and brain edema. On day 1 after tMCAO, DMF-treated mice showed reduced lymphocyte infiltration compared to controls, which was not observed on day 7. Monocyte and microglial cell counts did not differ between groups on either day. In the acute phase of stroke, DMF administration attenuated lymphocyte infiltration, probably due to its stabilizing effect on the BBB. This highlights the potential of DMF as a therapeutic candidate for mitigating immune cell-driven damage in stroke.
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Affiliation(s)
- Michael K. Schuhmann
- Department of Neurology, University Hospital Würzburg, Josef-Schneider Strasse 11, 97080 Würzburg, Germany; (M.K.S.); (L.Z.); (M.B.)
| | - Friederike Langhauser
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, 45147 Essen, Germany; (F.L.); (C.K.)
| | - Lena Zimmermann
- Department of Neurology, University Hospital Würzburg, Josef-Schneider Strasse 11, 97080 Würzburg, Germany; (M.K.S.); (L.Z.); (M.B.)
| | - Maximilian Bellut
- Department of Neurology, University Hospital Würzburg, Josef-Schneider Strasse 11, 97080 Würzburg, Germany; (M.K.S.); (L.Z.); (M.B.)
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, 45147 Essen, Germany; (F.L.); (C.K.)
| | - Felix Fluri
- Department of Neurology, University Hospital Würzburg, Josef-Schneider Strasse 11, 97080 Würzburg, Germany; (M.K.S.); (L.Z.); (M.B.)
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Haarmann A, Vollmuth C, Kollikowski AM, Heuschmann PU, Pham M, Stoll G, Neugebauer H, Schuhmann MK. Vasoactive Soluble Endoglin: A Novel Biomarker Indicative of Reperfusion after Cerebral Large-Vessel Occlusion. Cells 2023; 12:cells12020288. [PMID: 36672223 PMCID: PMC9856463 DOI: 10.3390/cells12020288] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Now that mechanical thrombectomy has substantially improved outcomes after large-vessel occlusion stroke in up to every second patient, futile reperfusion wherein successful recanalization is not followed by a favorable outcome is moving into focus. Unfortunately, blood-based biomarkers, which identify critical stages of hemodynamically compromised yet reperfused tissue, are lacking. We recently reported that hypoxia induces the expression of endoglin, a TGF-β co-receptor, in human brain endothelium in vitro. Subsequent reoxygenation resulted in shedding. Our cell model suggests that soluble endoglin compromises the brain endothelial barrier function. To evaluate soluble endoglin as a potential biomarker of reperfusion (-injury) we analyzed its concentration in 148 blood samples of patients with acute stroke due to large-vessel occlusion. In line with our in vitro data, systemic soluble endoglin concentrations were significantly higher in patients with successful recanalization, whereas hypoxia alone did not induce local endoglin shedding, as analyzed by intra-arterial samples from hypoxic vasculature. In patients with reperfusion, higher concentrations of soluble endoglin additionally indicated larger infarct volumes at admission. In summary, we give translational evidence that the sequence of hypoxia and subsequent reoxygenation triggers the release of vasoactive soluble endoglin in large-vessel occlusion stroke and can serve as a biomarker for severe ischemia with ensuing recanalization/reperfusion.
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Affiliation(s)
- Axel Haarmann
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany
- Correspondence: (A.H.); (M.K.S.)
| | - Christoph Vollmuth
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany
| | | | - Peter U. Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, 97080 Würzburg, Germany
- Clinical Trial Center, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Mirko Pham
- Department of Neuroradiology, University of Würzburg, 97080 Würzburg, Germany
| | - Guido Stoll
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany
| | - Michael K. Schuhmann
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany
- Correspondence: (A.H.); (M.K.S.)
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Bellut M, Bieber M, Kraft P, Weber ANR, Stoll G, Schuhmann MK. Delayed NLRP3 inflammasome inhibition ameliorates subacute stroke progression in mice. J Neuroinflammation 2023; 20:4. [PMID: 36600259 DOI: 10.1186/s12974-022-02674-w] [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: 06/22/2022] [Accepted: 12/15/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Ischemic stroke immediately evokes a strong neuro-inflammatory response within the vascular compartment, which contributes to primary infarct development under vessel occlusion as well as further infarct growth despite recanalization, referred to as ischemia/reperfusion injury. Later, in the subacute phase of stroke (beyond day 1 after recanalization), further inflammatory processes within the brain parenchyma follow. Whether this second wave of parenchymal inflammation contributes to an additional/secondary increase in infarct volumes and bears the potential to be pharmacologically targeted remains elusive. We addressed the role of the NLR-family pyrin domain-containing protein 3 (NLRP3) inflammasome in the subacute phase of ischemic stroke. METHODS Focal cerebral ischemia was induced in C57Bl/6 mice by a 30-min transient middle cerebral artery occlusion (tMCAO). Animals were treated with the NLRP3 inhibitor MCC950 therapeutically 24 h after or prophylactically before tMCAO. Stroke outcome, including infarct size and functional deficits as well as the local inflammatory response, was assessed on day 7 after tMCAO. RESULTS Infarct sizes on day 7 after tMCAO decreased about 35% after delayed and about 60% after prophylactic NLRP3 inhibition compared to vehicle. Functionally, pharmacological inhibition of NLRP3 mitigated the local inflammatory response in the ischemic brain as indicated by reduction of infiltrating immune cells and reactive astrogliosis. CONCLUSIONS Our results demonstrate that the NLRP3 inflammasome continues to drive neuroinflammation within the subacute stroke phase. NLRP3 inflammasome inhibition leads to a better long-term outcome-even when administered with a delay of 1 day after stroke induction, indicating ongoing inflammation-driven infarct progression. These findings may pave the way for eagerly awaited delayed treatment options in ischemic stroke.
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Affiliation(s)
- Maximilian Bellut
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Michael Bieber
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Peter Kraft
- Department of Neurology, Klinikum Main-Spessart Lohr, Lohr, Germany
| | - Alexander N R Weber
- Department of Immunology, Interfaculty Institute of Cell Biology, University of Tübingen, Tübingen, Germany.,iFIT-Clusters of Excellence EXC 2180 "Image-Guided and Functionally Instructed Tumor Therapies" and EXC 2124 "Controlling Microbes to Fight Infection", University of Tübingen, Tübingen, Germany
| | - Guido Stoll
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Michael K Schuhmann
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
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