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Thijs V, Cloud GC, Gilchrist N, Parsons B, Tilvawala F, Ho J, Ruthnam L, Stanislaus V, Sprigg N, Walker M, Bath PM, Churilov L, Bernhardt J. Perispinal Etanercept to improve STroke Outcomes (PESTO): Protocol for a multicenter, international, randomized placebo-controlled trial. Eur Stroke J 2024; 9:789-795. [PMID: 38676623 DOI: 10.1177/23969873241249248] [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: 04/29/2024] Open
Abstract
RATIONALE A large proportion of stroke survivors will have long-lasting, debilitating neurological impairments, yet few efficacious medical treatment options are available. Etanercept inhibits binding of tumor necrosis factor to its receptor and is used in the treatment of inflammatory conditions. Perispinal subcutaneous injection followed by a supine, head down position may bypass the blood brain barrier. In observational studies and one small randomized controlled trial the majority of patients showed improvement in multiple post stroke impairments. AIM Perispinal Etanercept to improve STroke Outcomes (PESTO) investigates whether perispinal subcutaneous injection of etanercept improves quality of life and is safe in patients with chronic, disabling, effects of stroke. METHODS AND DESIGN PESTO is a multicenter, international, randomized placebo-controlled trial. Adult participants with a history of stroke between 1 and 15 years before enrollment and a current modified Rankin scale between 2 and 5 who are otherwise eligible for etanercept are randomized 1:1 to single dose injection of etanercept or placebo. STUDY OUTCOMES The primary efficacy outcome is quality of life as measured using the Short Form 36 Health Inventory at day 28 after first injection. Safety outcomes include serious adverse events. SAMPLE SIZE TARGET A total of 168 participants assuming an improvement of the SF-36 in 11% of participants in the control arm and in 30% of participants in the intervention arm, 80% power and 5% alpha. DISCUSSION PESTO aims to provide level 1 evidence on the safety and efficacy of perispinal etanercept in patients with long-term disabling effects of stroke.
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Affiliation(s)
- Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, Melbourne Medical School, University of Melbourne, Heidelberg/Parkville, VIC Australia
| | - Geoffrey C Cloud
- Department of Neuroscience, Central Clinical School, Monash University Melbourne, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | | | - Brooke Parsons
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Forum Tilvawala
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Jan Ho
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Lara Ruthnam
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Vimal Stanislaus
- Department of Neuroscience, Central Clinical School, Monash University Melbourne, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Marion Walker
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Leonid Churilov
- Department of Medicine, Melbourne Medical School, University of Melbourne, Heidelberg/Parkville, VIC Australia
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
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Tobinick E, Ucci D, Bermudo K, Asseraf S. Perispinal etanercept stroke trial design: PESTO and beyond. Expert Opin Biol Ther 2024:1-14. [PMID: 39177653 DOI: 10.1080/14712598.2024.2390636] [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: 07/23/2024] [Accepted: 08/06/2024] [Indexed: 08/24/2024]
Abstract
INTRODUCTION Perispinal etanercept (PSE) is an innovative treatment designed to improve stroke recovery by addressing chronic post-stroke neuroinflammation. Basic science evidence, randomized clinical trial (RCT) evidence and 14 years of favorable clinical experience support the use of PSE to treat chronic stroke. This article provides guidance for the design of future PSE RCTs in accordance with current FDA recommendations. AREAS COVERED Scientific background and essential elements of PSE RCT design. EXPERT OPINION Intimate familiarity with PSE, its novel method of drug delivery, and the characteristics of ideal enriched study populations are necessary for those designing future PSE stroke trials. The design elements needed to enable a PSE RCT to generate valid results include a suitable research question; a homogeneous study population selected using a prospective enrichment strategy; a primary outcome measure responsive to the neurological improvements that result from PSE; trialists with expertise in perispinal delivery; optimal etanercept dosing; and steps taken to minimize the number of placebo responders. RCTs failing to incorporate these elements, such as the PESTO trial, are incapable of reaching reliable conclusions regarding PSE efficacy. SF-36 has not been validated in PSE trials and is unsuitable for use as a primary outcome measure in PSE RCTs.
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Affiliation(s)
| | - Danielle Ucci
- Institute of Neurological Recovery, Boca Raton, FL, USA
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Clark IA, Vissel B. Autocrine positive feedback of tumor necrosis factor from activated microglia proposed to be of widespread relevance in chronic neurological disease. Pharmacol Res Perspect 2023; 11:e01136. [PMID: 37750203 PMCID: PMC10520644 DOI: 10.1002/prp2.1136] [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: 06/29/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/27/2023] Open
Abstract
Over a decade's experience of post-stroke rehabilitation by administering the specific anti-TNF biological, etanercept, by the novel perispinal route, is consistent with a wide range of chronically diminished neurological function having been caused by persistent excessive cerebral levels of TNF. We propose that this TNF persistence, and cerebral disease chronicity, largely arises from a positive autocrine feedback loop of this cytokine, allowing the persistence of microglial activation caused by the excess TNF that these cells produce. It appears that many of these observations have never been exploited to construct a broad understanding and treatment of certain chronic, yet reversible, neurological illnesses. We propose that this treatment allows these chronically activated microglia to revert to their normal quiescent state, rather than simply neutralizing the direct harmful effects of this cytokine after its release from microglia. Logically, this also applies to the chronic cerebral aspects of various other neurological conditions characterized by activated microglia. These include long COVID, Lyme disease, post-stroke syndromes, traumatic brain injury, chronic traumatic encephalopathy, post-chemotherapy, post-irradiation cerebral dysfunction, cerebral palsy, fetal alcohol syndrome, hepatic encephalopathy, the antinociceptive state of morphine tolerance, and neurogenic pain. In addition, certain psychiatric states, in isolation or as sequelae of infectious diseases such as Lyme disease and long COVID, are candidates for being understood through this approach and treated accordingly. Perispinal etanercept provides the prospect of being able to treat various chronic central nervous system illnesses, whether they are of infectious or non-infectious origin, through reversing excess TNF generation by microglia.
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Affiliation(s)
- Ian A. Clark
- Research School of Biology, Australian National UniversityCanberraAustralian Capital TerritoryAustralia
| | - Bryce Vissel
- St Vincent's Hospital Centre for Applied Medical ResearchSt Vincent's HospitalDarlinghurstAustralia
- UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and HealthSchool of Clinical Medicine, UNSW SydneySydneyNew South WalesAustralia
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Gao Y, Fang C, Wang J, Ye Y, Li Y, Xu Q, Kang X, Gu L. Neuroinflammatory Biomarkers in the Brain, Cerebrospinal Fluid, and Blood After Ischemic Stroke. Mol Neurobiol 2023; 60:5117-5136. [PMID: 37258724 DOI: 10.1007/s12035-023-03399-4] [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: 11/29/2022] [Accepted: 05/23/2023] [Indexed: 06/02/2023]
Abstract
The most frequent type of stroke, known as ischemic stroke (IS), is a significant global public health issue. The pathological process of IS and post-IS episodes has not yet been fully explored, but neuroinflammation has been identified as one of the key processes. Biomarkers are objective indicators used to assess normal or pathological processes, evaluate responses to treatment, and predict outcomes, and some biomarkers can also be used as therapeutic targets. After IS, various molecules are produced by different cell types, such as microglia, astrocytes, infiltrating leukocytes, endothelial cells, and damaged neurons, that participate in the neuroinflammatory response within the ischemic brain region. These molecules may either promote or inhibit neuroinflammation and may be released into extracellular spaces, including cerebrospinal fluid (CSF) and blood, due to reasons such as BBB damage. These neuroinflammatory molecules should be valued as biomarkers to monitor whether their expression levels in the blood, CSF, and brain correlate with the diagnosis and prognosis of IS patients or whether they have potential as therapeutic targets. In addition, although some molecules do not directly participate in the process of neuroinflammation, they have been reported to have potential diagnostic or therapeutic value against post-IS neuroinflammation, and these molecules will also be listed. In this review, we summarize the neuroinflammatory biomarkers in the brain, CSF, and blood after an IS episode and the potential value of these biomarkers for the diagnosis, treatment, and prognosis of IS patients.
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Affiliation(s)
- Yikun Gao
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Congcong Fang
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Jin Wang
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Yingze Ye
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Yina Li
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Qingxue Xu
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Xianhui Kang
- Department of Anesthesia, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, 310006, China.
| | - Lijuan Gu
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China.
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Cao Y, Yue X, Jia M, Wang J. Neuroinflammation and anti-inflammatory therapy for ischemic stroke. Heliyon 2023; 9:e17986. [PMID: 37519706 PMCID: PMC10372247 DOI: 10.1016/j.heliyon.2023.e17986] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 04/25/2023] [Accepted: 07/04/2023] [Indexed: 08/01/2023] Open
Abstract
Stroke remains one of the most devastating and challenging neurological diseases worldwide. Inflammation, as well as oxidative stress is one of the main contributors to post-stroke injuries, and oxidative stress can further induce inflammation. Moreover, the inflammatory response is closely related to immune modulation in ischemic stroke progression. Hence, major ischemic stroke treatment strategies include targeting inflammatory responses, immune modulation (especially immune cells), and inflammatory response to suppress stroke progression. To date, several drugs have demonstrated clinical efficacy, such as Etanercept and Fingolimod. However, only edaravone dexborneol has successfully passed the phase III clinical trial and been approved by the National Medical Products Administration (NMPA) to treat ischemic stroke in China, which can restore redox balance and regulate inflammatory immune responses, thus providing neuroprotection in ischemic stroke. In this review, we will comprehensively summarize the current advances in the application of inflammatory biomarkers, neuroinflammation and neuro-immunotherapeutic scenarios for ischemic stroke, thus aiming to provide a theoretical basis and new prospects and frontiers for clinical applications.
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Affiliation(s)
- Yangyue Cao
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xuanye Yue
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Meng Jia
- National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Joseph AM, Karas M, Jara Silva CE, Leyva M, Salam A, Sinha M, Asfaw YA, Fonseca A, Cordova S, Reyes M, Quinonez J, Ruxmohan S. The Potential Role of Etanercept in the Management of Post-stroke Pain: A Literature Review. Cureus 2023; 15:e36185. [PMID: 37065345 PMCID: PMC10103818 DOI: 10.7759/cureus.36185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/15/2023] [Indexed: 03/17/2023] Open
Abstract
Strokes are the second leading cause of death and disability worldwide. The brain injury resulting from stroke produces a persistent neuroinflammatory response in the brain, resulting in a spectrum of neurologic dysfunction affecting stroke survivors chronically, also known as post-stroke pain. Excess production of tumor necrosis factor alpha (TNF alpha) in the cerebrospinal fluid (CSF) of stroke survivors has been implicated in post-stroke pain. Therefore, this literature review aims to assess and review the role of perispinal etanercept in the management of post-stroke pain. Several studies have shown statistically significant evidence that etanercept, a TNF alpha inhibitor, can reduce symptoms present in post-stroke syndrome by targeting the excess TNF alpha produced in the CSF. Studies have also shown improvements in not only post-stroke pain but also in traumatic brain injury and dementia. Further research is needed to explore the effects of TNF alpha on stroke prognosis and determine the optimal frequency and duration of etanercept treatment for post-stroke pain.
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Blaylock RL. The biochemical basis of neurodegenerative disease: The role of immunoexcitoxicity and ways to possibly attenuate it. Surg Neurol Int 2023; 14:141. [PMID: 37151454 PMCID: PMC10159298 DOI: 10.25259/sni_250_2023] [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: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 05/09/2023] Open
Abstract
There is growing evidence that inflammation secondary to immune activation is intimately connected to excitotoxicity. We now know that most peripheral tissues contain fully operational glutamate receptors. While most of the available research deals with excitotoxicity in central nervous system (CNS) tissues, this is no longer true. Even plant has been found to contain glutamate receptors. Most of the immune cells, including mask cells, contain glutamate receptors. The receptors are altered by inflammation, both chemokine and cytokines. A host of new diseases have been found that are caused by immunity to certain glutamate receptors, as we see with Rasmussen's encephalitis. In this paper, I try to explain this connection and possible ways to reduce or even stop the reaction.
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Affiliation(s)
- Russell L. Blaylock
- Corresponding author: Russell L. Blaylock, M.D. 609 Old Natchez Trace Canton, MS. Retired Neurosurgeon, Department of Neurosurgery, Theoretical Neuroscience Research, LLC, Ridgeland, Mississippi, United States.
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Tobinick E, Spengler RN, Ignatowski TA, Wassel M, Laborde S. Rapid improvement in severe long COVID following perispinal etanercept. Curr Med Res Opin 2022; 38:2013-2020. [PMID: 35791687 DOI: 10.1080/03007995.2022.2096351] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND This study aimed to describe the neurological improvements in a patient with severe long COVID brain dysfunction following perispinal etanercept administration. Perispinal administration of etanercept, a novel method designed to enhance its brain delivery via carriage in the cerebrospinal venous system, has previously been shown to reduce chronic neurological dysfunction after stroke. Etanercept is a recombinant biologic that is capable of ameliorating two components of neuroinflammation: microglial activation and the excess bioactivity of tumor necrosis factor (TNF), a proinflammatory cytokine that is a key neuromodulator in the brain. Optimal synaptic and brain network function require physiological levels of TNF. Neuroinflammation, including brain microglial activation and excess central TNF, can be a consequence of stroke or peripheral infection, including infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. METHODS Standardized, validated measures, including the Montreal Cognitive Assessment, Beck Depression Index-II (BDI-II), Fatigue Assessment Scale, Controlled Oral Word Association Test, Trail Making Tests, Timed Finger-to-Nose Test, 20 m Self-Paced Walk Test, 5 Times Sit-to-Stand Test and Grip Strength measured with a Jamar Dynamometer were used to quantitate changes in cognition, depression, fatigue and neurological function after a single 25 mg perispinal etanercept dose in a patient with severe long COVID of 12 months duration. RESULTS Following perispinal etanercept administration there was immediate neurological improvement. At 24 h, there were remarkable reductions in chronic post-COVID-19 fatigue and depression, and significant measurable improvements in cognition, executive function, phonemic verbal fluency, balance, gait, upper limb coordination and grip strength. Cognition, depression and fatigue were examined at 29 days; each remained substantially improved. CONCLUSION Perispinal etanercept is a promising treatment for the chronic neurologic dysfunction that may persist after resolution of acute COVID-19, including chronic cognitive dysfunction, fatigue, and depression. These results suggest that long COVID brain neuroinflammation is a potentially reversible pathology and viable treatment target. In view of the increasing unmet medical need, clinical trials of perispinal etanercept for long COVID are urgently necessary. The robust results of the present case suggest that perispinal etanercept clinical trials studying long COVID populations with severe fatigue, depression and cognitive dysfunction may have improved ability to detect a treatment effect. Positron emission tomographic methods that image brain microglial activation and measurements of cerebrospinal fluid proinflammatory cytokines may be useful for patient selection and correlation with treatment effects, as well as provide insight into the underlying pathophysiology.
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Affiliation(s)
| | | | - Tracey A Ignatowski
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Manar Wassel
- Institute of Neurological Recovery, Boca Raton, FL, USA
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9
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DeLong JH, Ohashi SN, O'Connor KC, Sansing LH. Inflammatory Responses After Ischemic Stroke. Semin Immunopathol 2022; 44:625-648. [PMID: 35767089 DOI: 10.1007/s00281-022-00943-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/20/2022] [Indexed: 12/25/2022]
Abstract
Ischemic stroke generates an immune response that contributes to neuronal loss as well as tissue repair. This is a complex process involving a range of cell types and effector molecules and impacts tissues outside of the CNS. Recent reviews address specific aspects of this response, but several years have passed and important advances have been made since a high-level review has summarized the overall state of the field. The present review examines the initiation of the inflammatory response after ischemic stroke, the complex impacts of leukocytes on patient outcome, and the potential of basic science discoveries to impact the development of therapeutics. The information summarized here is derived from broad PubMed searches and aims to reflect recent research advances in an unbiased manner. We highlight valuable recent discoveries and identify gaps in knowledge that have the potential to advance our understanding of this disease and therapies to improve patient outcomes.
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Affiliation(s)
- Jonathan Howard DeLong
- Departments of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Sarah Naomi Ohashi
- Departments of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin Charles O'Connor
- Departments of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Lauren Hachmann Sansing
- Departments of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA.
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Saba J, Couselo FL, Bruno J, Carniglia L, Durand D, Lasaga M, Caruso C. Neuroinflammation in Huntington's Disease: A Starring Role for Astrocyte and Microglia. Curr Neuropharmacol 2022; 20:1116-1143. [PMID: 34852742 PMCID: PMC9886821 DOI: 10.2174/1570159x19666211201094608] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/06/2021] [Accepted: 11/26/2021] [Indexed: 11/22/2022] Open
Abstract
Huntington's disease (HD) is a neurodegenerative genetic disorder caused by a CAG repeat expansion in the huntingtin gene. HD causes motor, cognitive, and behavioral dysfunction. Since no existing treatment affects the course of this disease, new treatments are needed. Inflammation is frequently observed in HD patients before symptom onset. Neuroinflammation, characterized by the presence of reactive microglia, astrocytes and inflammatory factors within the brain, is also detected early. However, in comparison to other neurodegenerative diseases, the role of neuroinflammation in HD is much less known. Work has been dedicated to altered microglial and astrocytic functions in the context of HD, but less attention has been given to glial participation in neuroinflammation. This review describes evidence of inflammation in HD patients and animal models. It also discusses recent knowledge on neuroinflammation in HD, highlighting astrocyte and microglia involvement in the disease and considering anti-inflammatory therapeutic approaches.
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Affiliation(s)
- Julieta Saba
- Instituto de Investigaciones Biomédicas (INBIOMED), UBA-CONICET, Paraguay 2155, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Federico López Couselo
- Instituto de Investigaciones Biomédicas (INBIOMED), UBA-CONICET, Paraguay 2155, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Julieta Bruno
- Instituto de Investigaciones Biomédicas (INBIOMED), UBA-CONICET, Paraguay 2155, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Lila Carniglia
- Instituto de Investigaciones Biomédicas (INBIOMED), UBA-CONICET, Paraguay 2155, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Daniela Durand
- Instituto de Investigaciones Biomédicas (INBIOMED), UBA-CONICET, Paraguay 2155, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Mercedes Lasaga
- Instituto de Investigaciones Biomédicas (INBIOMED), UBA-CONICET, Paraguay 2155, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Carla Caruso
- Instituto de Investigaciones Biomédicas (INBIOMED), UBA-CONICET, Paraguay 2155, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina,Address correspondence to this author at the Instituto de Investigaciones Biomédicas (INBIOMED), UBA-CONICET, Paraguay 2155 Piso 10, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina, Tel: +54 11 5285 3380; E-mail:
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Clark IA. Chronic cerebral aspects of long COVID, post-stroke syndromes and similar states share their pathogenesis and perispinal etanercept treatment logic. Pharmacol Res Perspect 2022; 10:e00926. [PMID: 35174650 PMCID: PMC8850677 DOI: 10.1002/prp2.926] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 12/15/2022] Open
Abstract
The chronic neurological aspects of traumatic brain injury, post-stroke syndromes, long COVID-19, persistent Lyme disease, and influenza encephalopathy having close pathophysiological parallels that warrant being investigated in an integrated manner. A mechanism, common to all, for this persistence of the range of symptoms common to these conditions is described. While TNF maintains cerebral homeostasis, its excessive production through either pathogen-associated molecular patterns or damage-associated molecular patterns activity associates with the persistence of the symptoms common across both infectious and non-infectious conditions. The case is made that this shared chronicity arises from a positive feedback loop causing the persistence of the activation of microglia by the TNF that these cells generate. Lowering this excess TNF is the logical way to reducing this persistent, TNF-maintained, microglial activation. While too large to negotiate the blood-brain barrier effectively, the specific anti-TNF biological, etanercept, shows promise when administered by the perispinal route, which allows it to bypass this obstruction.
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Affiliation(s)
- Ian Albert Clark
- Research School of BiologyAustralian National UniversityCanberraACTAustralia
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12
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Stamatovic SM, Phillips CM, Keep RF, Andjelkovic AV. An In Vivo Mouse Model to Study Blood-Brain Barrier Destabilization in the Chronic Phase of Stroke. Methods Mol Biol 2022; 2492:289-305. [PMID: 35733052 DOI: 10.1007/978-1-0716-2289-6_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Cerebral ischemic injury evokes a complex cascade of pathophysiological events at the blood-vascular-parenchymal interface. These evolve over time and space and result in progressive neurological damage. Emerging evidence suggests that blood-brain barrier (BBB) recovery and reestablishment of BBB impermeability are incomplete and that these could influence stroke injury recovery, increase the risk of new stroke occurrence, and be a solid substrate for developing vascular dementia. Recent work from the author's laboratory has established the existence of incomplete BBB recovery in chronic stroke conditions that was induced by structural alterations to brain endothelial junctional complexes and persistent BBB leakage. The experimental methodology presented here is focused on modelling chronic stroke injury using an in vivo thromboembolic mouse stroke model and how to evaluate the kinetics and magnitude of BBB hyperpermeability in chronic stroke conditions using a combination of magnetic resonance imaging, tracer studies, and immunohistochemistry.
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Affiliation(s)
| | - Chelsea M Phillips
- Graduate Program in Neuroscience, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anuska V Andjelkovic
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI, USA.
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Clark IA. How diseases caused by parasites allowed a wider understanding of disease in general: my encounters with parasitology in Australia and elsewhere over the last 50 years. Int J Parasitol 2021; 51:1265-1276. [PMID: 34757090 DOI: 10.1016/j.ijpara.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/18/2021] [Accepted: 10/13/2021] [Indexed: 12/18/2022]
Abstract
This is an account of how it can prove possible to carve a reasonable scientific career by following what brought most scientific thrill rather than pursue a safe, institution-directed, path. The fascination began when I noticed, quite unexpectedly, that the normal mouse immune response causes Babesia microti to die, en masse, inside circulating red cells. It eventuated that prior Bacillus Calmette Guerin infection caused the same outcome, even before the protozoal infection became patent. It also rendered mice quite immune, long term. I acquired an obsession about this telling us how little we know. Surrounded by basic immunologists, parasitologists and virologists in London, I had been given, in the days that funding was ample, the opportunity to follow any promising lead with a free hand. Through Bacillus Calmette Guerin, this meant stumbling through a set of phenomena that were in their infancies, and could be explained only through nebulous novel soluble mediators such as TNF, described the following year as causing the in vivo necrosis of tumours in mice. Beginning with malarial disease pathogenesis, I followed TNF wherever it led, into innate immunity, acute and chronic infections, neurophysiology and neurodegenerative diseases, in all of which states awareness of the role of this cytokine is still growing fast. Many of these steps can be illustrated and expanded upon in parasitic diseases. Covering the importance of TNF in the pathogenesis of neurodegenerative disease has proved to be highly illuminating, scientifically and otherwise. But the insights it has given me into understanding the temptations to which patent-owners can succumb when faced with opportunities to put money before people is not for the faint hearted. Clearly, parasitologists inhabit a much more common-good yet science-orientated, civilised, world.
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Affiliation(s)
- Ian A Clark
- Biomedical Sciences and Biochemistry, Research School of Biology, Australian National University, Canberra, ACT 2601, Australia.
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Cruz SA, Qin Z, Ricke KM, Stewart AFR, Chen HH. Neuronal protein-tyrosine phosphatase 1B hinders sensory-motor functional recovery and causes affective disorders in two different focal ischemic stroke models. Neural Regen Res 2021; 16:129-136. [PMID: 32788467 PMCID: PMC7818877 DOI: 10.4103/1673-5374.286970] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Ischemic brain injury causes neuronal death and inflammation. Inflammation activates protein-tyrosine phosphatase 1B (PTP1B). Here, we tested the significance of PTP1B activation in glutamatergic projection neurons on functional recovery in two models of stroke: by photothrombosis, focal ischemic lesions were induced in the sensorimotor cortex (SM stroke) or in the peri-prefrontal cortex (peri-PFC stroke). Elevated PTP1B expression was detected at 4 days and up to 6 weeks after stroke. While ablation of PTP1B in neurons of neuronal knockout (NKO) mice had no effect on the volume or resorption of ischemic lesions, markedly different effects on functional recovery were observed. SM stroke caused severe sensory and motor deficits (adhesive removal test) in wild type and NKO mice at 4 days, but NKO mice showed drastically improved sensory and motor functional recovery at 8 days. In addition, peri-PFC stroke caused anxiety-like behaviors (elevated plus maze and open field tests), and depression-like behaviors (forced swimming and tail suspension tests) in wild type mice 9 and 28 days after stroke, respectively, with minimal effect on sensory and motor function. Peri-PFC stroke-induced affective disorders were associated with fewer active (FosB+) neurons in the PFC and nucleus accumbens but more FosB+ neurons in the basolateral amygdala, compared to sham-operated mice. In contrast, mice with neuronal ablation of PTP1B were protected from anxiety-like and depression-like behaviors and showed no change in FosB+ neurons after peri-PFC stroke. Taken together, our study identifies neuronal PTP1B as a key component that hinders sensory and motor functional recovery and also contributes to the development of anxiety-like and depression-like behaviors after stroke. Thus, PTP1B may represent a novel therapeutic target to improve stroke recovery. All procedures for animal use were approved by the Animal Care and Use Committee of the University of Ottawa Animal Care and Veterinary Service (protocol 1806) on July 27, 2018.
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Affiliation(s)
- Shelly A Cruz
- Ottawa Hospital Research Institute, Neuroscience Program; Brain and Mind Institute, University of Ottawa, Ottawa, ON, Canada
| | - Zhaohong Qin
- Ottawa Hospital Research Institute, Neuroscience Program; Brain and Mind Institute, University of Ottawa, Ottawa, ON, Canada
| | - Konrad M Ricke
- Brain and Mind Institute; Department of Biochemistry, Microbiology and Immunology, University of Ottawa; University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Alexandre F R Stewart
- Department of Biochemistry, Microbiology and Immunology; Centre for Infection, Immunity and Inflammation, University of Ottawa; University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Hsiao-Huei Chen
- Ottawa Hospital Research Institute, Neuroscience Program; Brain and Mind Institute; Cellular and Molecular Medicine; Department of Medicine; Centre for Infection, Immunity and Inflammation, University of Ottawa, Ottawa, ON, Canada
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15
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Clark I, Vissel B. Broader Insights into Understanding Tumor Necrosis Factor and Neurodegenerative Disease Pathogenesis Infer New Therapeutic Approaches. J Alzheimers Dis 2021; 79:931-948. [PMID: 33459706 PMCID: PMC7990436 DOI: 10.3233/jad-201186] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/12/2022]
Abstract
Proinflammatory cytokines such as tumor necrosis factor (TNF), with its now appreciated key roles in neurophysiology as well as neuropathophysiology, are sufficiently well-documented to be useful tools for enquiry into the natural history of neurodegenerative diseases. We review the broader literature on TNF to rationalize why abruptly-acquired neurodegenerative states do not exhibit the remorseless clinical progression seen in those states with gradual onsets. We propose that the three typically non-worsening neurodegenerative syndromes, post-stroke, post-traumatic brain injury (TBI), and post cardiac arrest, usually become and remain static because of excess cerebral TNF induced by the initial dramatic peak keeping microglia chronically activated through an autocrine loop of microglial activation through excess cerebral TNF. The existence of this autocrine loop rationalizes post-damage repair with perispinal etanercept and proposes a treatment for cerebral aspects of COVID-19 chronicity. Another insufficiently considered aspect of cerebral proinflammatory cytokines is the fitness of the endogenous cerebral anti-TNF system provided by norepinephrine (NE), generated and distributed throughout the brain from the locus coeruleus (LC). We propose that an intact LC, and therefore an intact NE-mediated endogenous anti-cerebral TNF system, plus the DAMP (damage or danger-associated molecular pattern) input having diminished, is what allows post-stroke, post-TBI, and post cardiac arrest patients a strong long-term survival advantage over Alzheimer's disease and Parkinson's disease sufferers. In contrast, Alzheimer's disease and Parkinson's disease patients remorselessly worsen, being handicapped by sustained, accumulating, DAMP and PAMP (pathogen-associated molecular patterns) input, as well as loss of the LC-origin, NE-mediated, endogenous anti-cerebral TNF system. Adrenergic receptor agonists may counter this.
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Affiliation(s)
- I.A. Clark
- Research School of Biology, Australian National University, Canberra, Australia
| | - B. Vissel
- Centre for Neuroscience and Regenerative Medicine, Faculty of Science, University of Technology, Sydney, Australia
- St. Vincent’s Centre for Applied Medical Research, Sydney, Australia
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16
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Clark IA. Randomized controlled trial validating the use of perispinal etanercept to reduce post-stroke disability has wide-ranging implications. Expert Rev Neurother 2020; 20:203-205. [PMID: 32028804 DOI: 10.1080/14737175.2020.1727742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Developing effective drug treatments for neurodegenerative disorders has always been hamstrung by the accepted inability of large molecules (roughly those with a molecular weight greater than 600 Daltons) to cross the blood-brain barrier (BBB) in therapeutic quantities when administered systemically. The dogma has been that a simple, noninvasive way to accomplish this goal is not possible with many agents, including biologicals, because they are too large. Various novel technologies to breach the BBB have been attempted, but with little success. A randomized double-blind, placebo-controlled clinical trial (RCT) administering a widely used anti-tumor necrosis factor (TNF) biological, etanercept, given via perispinal injection, which bypasses the BBB, turns this dogma on its head. This new trial holds much promise for stroke survivors, as well as having implications for developing treatments based on other large molecules for this and other brain disorders.
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Affiliation(s)
- Ian A Clark
- Research School of Biology, Australian National University, Canberra, Australia
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17
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Subedi L, Lee SE, Madiha S, Gaire BP, Jin M, Yumnam S, Kim SY. Phytochemicals against TNFα-Mediated Neuroinflammatory Diseases. Int J Mol Sci 2020; 21:ijms21030764. [PMID: 31991572 PMCID: PMC7037901 DOI: 10.3390/ijms21030764] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 02/07/2023] Open
Abstract
Tumor necrosis factor-alpha (TNF-α) is a well-known pro-inflammatory cytokine responsible for the modulation of the immune system. TNF-α plays a critical role in almost every type of inflammatory disorder, including central nervous system (CNS) diseases. Although TNF-α is a well-studied component of inflammatory responses, its functioning in diverse cell types is still unclear. TNF-α functions through its two main receptors: tumor necrosis factor receptor 1 and 2 (TNFR1, TNFR2), also known as p55 and p75, respectively. Normally, the functions of soluble TNF-α-induced TNFR1 activation are reported to be pro-inflammatory and apoptotic. While TNF-α mediated TNFR2 activation has a dual role. Several synthetic drugs used as inhibitors of TNF-α for diverse inflammatory diseases possess serious adverse effects, which make patients and researchers turn their focus toward natural medicines, phytochemicals in particular. Phytochemicals targeting TNF-α can significantly improve disease conditions involving TNF-α with fewer side effects. Here, we reviewed known TNF-α inhibitors, as well as lately studied phytochemicals, with a role in inhibiting TNF-α itself, and TNF-α-mediated signaling in inflammatory diseases focusing mainly on CNS disorders.
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Affiliation(s)
- Lalita Subedi
- College of Pharmacy, Gachon University, #191, Hambakmoero, Yeonsu-gu, Incheon 21936, Korea; (L.S.); (S.E.L.); (B.P.G.)
| | - Si Eun Lee
- College of Pharmacy, Gachon University, #191, Hambakmoero, Yeonsu-gu, Incheon 21936, Korea; (L.S.); (S.E.L.); (B.P.G.)
| | - Syeda Madiha
- Neurochemistry and Biochemical Neuropharmacology Research Unit, Department of Biochemistry, University of Karachi, Karachi-75270, Pakistan;
| | - Bhakta Prasad Gaire
- College of Pharmacy, Gachon University, #191, Hambakmoero, Yeonsu-gu, Incheon 21936, Korea; (L.S.); (S.E.L.); (B.P.G.)
| | - Mirim Jin
- College of Medicine and Department of Health Science and Technology, GAIHST, Gachon University #155, Gaebeol-ro, Yeonsu-gu, Incheon 21999, Korea;
| | - Silvia Yumnam
- College of Pharmacy, Gachon University, #191, Hambakmoero, Yeonsu-gu, Incheon 21936, Korea; (L.S.); (S.E.L.); (B.P.G.)
- Correspondence: (S.Y.); (S.Y.K.); Tel.: +82-32-820-4931 (S.Y. & S.Y.K.); Fax: +82-32-820-4932 (S.Y. & S.Y.K.)
| | - Sun Yeou Kim
- College of Pharmacy, Gachon University, #191, Hambakmoero, Yeonsu-gu, Incheon 21936, Korea; (L.S.); (S.E.L.); (B.P.G.)
- Correspondence: (S.Y.); (S.Y.K.); Tel.: +82-32-820-4931 (S.Y. & S.Y.K.); Fax: +82-32-820-4932 (S.Y. & S.Y.K.)
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18
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Ralph SJ, Weissenberger A, Bonev V, King LD, Bonham MD, Ferguson S, Smith AD, Goodman-Jones AA, Espinet AJ. Phase I/II parallel double-blind randomized controlled clinical trial of perispinal etanercept for chronic stroke: improved mobility and pain alleviation. Expert Opin Investig Drugs 2020; 29:311-326. [PMID: 31899977 DOI: 10.1080/13543784.2020.1709822] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Previous open-label studies showed that chronic post-stroke pain could be abated by treatment with perispinal etanercept, although these benefits were questioned. A randomized double-blind placebo controlled clinical trial was conducted to test perispinal etanercept for chronic post-stroke pain.Research design and methods: Participants received two treatments, either perispinal etanercept (active) or saline (control). Primary outcomes were the differences in daily pain levels between groups analyzed by SPSS.Results: On the 0-100 points visual analog scale, perispinal etanercept reduced mean levels for worst and average daily pain from baseline after two treatments by 19.5 - 24 points (p < 0.05), and pain alleviation was maintained in the etanercept group, with no significant change in the control group. Thirty percent of etanercept participants had near complete pain abatement after first treatment. Goniometry of the paretic arm showed improved mean shoulder rotation by 55 degrees in active forward flexion for the etanercept group (p = 0.003) only.Conclusions: Perispinal etanercept can provide significant and ongoing benefits for the chronic post-stroke management of pain and greater shoulder flexion by the paretic arm. Effects are rapid and highly significant, supporting direct action on brain function.Trial registration: ACTRN12615001377527 and Universal Trial Number U1111-1174-3242.
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Affiliation(s)
- Stephen J Ralph
- School of Medical Science, Griffith University, Southport, Australia
| | | | | | - Liam D King
- School of Pharmacy, Griffith University, Southport, Australia
| | - Mikaela D Bonham
- School of Applied Psychology, Griffith University, Southport, Australia
| | - Samantha Ferguson
- School of Allied Health Sciences, Menzies Health Institute, Griffith University, Southport, Australia
| | - Ashley D Smith
- School of Allied Health Sciences, Menzies Health Institute, Griffith University, Southport, Australia.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
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19
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Tobinick E. Immediate Resolution of Hemispatial Neglect and Central Post-Stroke Pain After Perispinal Etanercept: Case Report. Clin Drug Investig 2020; 40:93-97. [PMID: 31642048 PMCID: PMC6962280 DOI: 10.1007/s40261-019-00864-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Edward Tobinick
- Institute of Neurological Recovery, 1877 S. Federal Highway, Suite 110, Boca Raton, FL, 33432, USA.
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20
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LaMacchia ZM, Spengler RN, Jaffari M, Abidi AH, Ahmed T, Singh N, Tobinick EL, Ignatowski TA. Perispinal injection of a TNF blocker directed to the brain of rats alleviates the sensory and affective components of chronic constriction injury-induced neuropathic pain. Brain Behav Immun 2019; 82:93-105. [PMID: 31376497 DOI: 10.1016/j.bbi.2019.07.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/12/2022] Open
Abstract
Neuropathic pain is chronic pain that follows nerve injury, mediated in the brain by elevated levels of the inflammatory protein tumor necrosis factor-alpha (TNF). We have shown that peripheral nerve injury increases TNF in the hippocampus/pain perception region, which regulates neuropathic pain symptoms. In this study we assessed pain sensation and perception subsequent to specific targeting of brain-TNF (via TNF antibody) administered through a novel subcutaneous perispinal route. Neuropathic pain was induced in Sprague-Dawley rats via chronic constriction injury (CCI), and thermal hyperalgesia was monitored for 10 days post-surgery. On day 8 following CCI and sensory pain behavior testing, rats were randomized to receive perispinal injection of TNF antibody or control IgG isotype antibody. Pain perception was assessed using conditioned place preference (CPP) to the analgesic, amitriptyline. CCI-rats receiving the perispinal injection of TNF antibody had significantly decreased CCI-induced thermal hyperalgesia the following day, and did not form an amitriptyline-induced CPP, whereas CCI-rats receiving perispinal IgG antibody experienced pain alleviation only in conjunction with i.p. amitriptyline and did form an amitriptyline-induced CPP. The specific targeting of brain TNF via perispinal delivery alleviates thermal hyperalgesia and positively influences the affective component of pain. PERSPECTIVE: This study presents a novel route of drug administration to target central TNF for treatment of neuropathic pain. Targeting central TNF through perispinal drug delivery could potentially be a more efficient and sustained method to treat patients with neuropathic pain.
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Affiliation(s)
- Zach M LaMacchia
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, USA
| | | | - Muhammad Jaffari
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, USA
| | - Asif H Abidi
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, USA
| | - Tariq Ahmed
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, USA
| | - Natasha Singh
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, USA
| | | | - Tracey A Ignatowski
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, USA; Program for Neuroscience, University at Buffalo, The State University of New York, USA.
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21
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Yli-Karjanmaa M, Clausen BH, Degn M, Novrup HG, Ellman DG, Toft-Jensen P, Szymkowski DE, Stensballe A, Meyer M, Brambilla R, Lambertsen KL. Topical Administration of a Soluble TNF Inhibitor Reduces Infarct Volume After Focal Cerebral Ischemia in Mice. Front Neurosci 2019; 13:781. [PMID: 31440125 PMCID: PMC6692878 DOI: 10.3389/fnins.2019.00781] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/11/2019] [Indexed: 01/05/2023] Open
Abstract
Background Tumor necrosis factor, which exists both as a soluble (solTNF) and a transmembrane (tmTNF) protein, plays an important role in post-stroke inflammation. The objective of the present study was to test the effect of topical versus intracerebroventricular administration of XPro1595 (a solTNF inhibitor) and etanercept (a solTNF and tmTNF inhibitor) compared to saline on output measures such as infarct volume and post-stroke inflammation in mice. Methods Adult male C57BL/6 mice were treated topically (2.5 mg/ml/1μl/h for 3 consecutive days) or intracerebroventricularly (1.25 mg/kg/0.5 ml, once) with saline, XPro1595, or etanercept immediately after permanent middle cerebral artery occlusion (pMCAO). Mice were allowed to survive 1 or 3 days. Infarct volume, microglial and leukocyte profiles, and inflammatory markers were evaluated. Results We found that topical, and not intracerebroventricular, administration of XPro1595 reduced infarct volume at both 1 and 3 days after pMCAO. Etanercept showed no effect. We observed no changes in microglial or leukocyte populations. XPro1595 increased gene expression of P2ry12 at 1 day and Trem2 at 1 and 3 days, while decreasing Cx3cr1 expression at 1 and 3 days after pMCAO, suggesting a change in microglial activation toward a phagocytic phenotype. Conclusion Our data demonstrate that topical administration of XPro1595 for 3 consecutive days decreases infarct volumes after ischemic stroke, while modifying microglial activation and the inflammatory response post-stroke. This suggests that inhibitors of solTNF hold great promise for future neuroprotective treatment in ischemic stroke.
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Affiliation(s)
- Minna Yli-Karjanmaa
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Bettina Hjelm Clausen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Matilda Degn
- Pediatric Oncology Laboratory, Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Hans Gram Novrup
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Ditte Gry Ellman
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Peter Toft-Jensen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Allan Stensballe
- Department of Health Science and Technology, University of Aalborg, Aalborg, Denmark
| | - Morten Meyer
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Roberta Brambilla
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Kate Lykke Lambertsen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,BRIDGE - Brain Research Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Neurology, Odense University Hospital, Odense, Denmark
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22
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Clark IA, Vissel B. Neurodegenerative disease treatments by direct TNF reduction, SB623 cells, maraviroc and irisin and MCC950, from an inflammatory perspective – a Commentary. Expert Rev Neurother 2019; 19:535-543. [DOI: 10.1080/14737175.2019.1618710] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- I A Clark
- Research School of Biology, Australian National University, Canberra, Australia
| | - B Vissel
- Centre for Neuroscience and Regenerative Medicine, Faculty of Science, University of Technology, Sydney, Australia
- St. Vincent’s Centre for Applied Medical Research, Sydney, New South Wales, Australia
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23
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Lambertsen KL, Finsen B, Clausen BH. Post-stroke inflammation-target or tool for therapy? Acta Neuropathol 2019; 137:693-714. [PMID: 30483945 PMCID: PMC6482288 DOI: 10.1007/s00401-018-1930-z] [Citation(s) in RCA: 274] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/03/2018] [Accepted: 11/04/2018] [Indexed: 12/22/2022]
Abstract
Inflammation is currently considered a prime target for the development of new stroke therapies. In the acute phase of ischemic stroke, microglia are activated and then circulating immune cells invade the peri-infarct and infarct core. Resident and infiltrating cells together orchestrate the post-stroke inflammatory response, communicating with each other and the ischemic neurons, through soluble and membrane-bound signaling molecules, including cytokines. Inflammation can be both detrimental and beneficial at particular stages after a stroke. While it can contribute to expansion of the infarct, it is also responsible for infarct resolution, and influences remodeling and repair. Several pre-clinical and clinical proof-of-concept studies have suggested the effectiveness of pharmacological interventions that target inflammation post-stroke. Experimental evidence shows that targeting certain inflammatory cytokines, such as tumor necrosis factor, interleukin (IL)-1, IL-6, and IL-10, holds promise. However, as these cytokines possess non-redundant protective and immunoregulatory functions, their neutralization or augmentation carries a risk of unwanted side effects, and clinical translation is, therefore, challenging. This review summarizes the cell biology of the post-stroke inflammatory response and discusses pharmacological interventions targeting inflammation in the acute phase after a stroke that may be used alone or in combination with recanalization therapies. Development of next-generation immune therapies should ideally aim at selectively neutralizing pathogenic immune signaling, enhancing tissue preservation, promoting neurological recovery and leaving normal function intact.
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Affiliation(s)
- Kate Lykke Lambertsen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000, Odense, Denmark.
- Department of Clinical Research, BRIDGE-Brain Research-Inter-Disciplinary Guided Excellence, University of Southern Denmark, 5000, Odense C, Denmark.
- Department of Neurology, Odense University Hospital, 5000, Odense, Denmark.
| | - Bente Finsen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000, Odense, Denmark
- Department of Clinical Research, BRIDGE-Brain Research-Inter-Disciplinary Guided Excellence, University of Southern Denmark, 5000, Odense C, Denmark
| | - Bettina Hjelm Clausen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, 5000, Odense, Denmark
- Department of Clinical Research, BRIDGE-Brain Research-Inter-Disciplinary Guided Excellence, University of Southern Denmark, 5000, Odense C, Denmark
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24
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Clark IA, Vissel B. Therapeutic implications of how TNF links apolipoprotein E, phosphorylated tau, α-synuclein, amyloid-β and insulin resistance in neurodegenerative diseases. Br J Pharmacol 2018; 175:3859-3875. [PMID: 30097997 PMCID: PMC6151331 DOI: 10.1111/bph.14471] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/26/2018] [Accepted: 07/23/2018] [Indexed: 12/24/2022] Open
Abstract
While cytokines such as TNF have long been recognized as essential to normal cerebral physiology, the implications of their chronic excessive production within the brain are now also increasingly appreciated. Syndromes as diverse as malaria and lead poisoning, as well as non‐infectious neurodegenerative diseases, illustrate this. These cytokines also orchestrate changes in tau, α‐synuclein, amyloid‐β levels and degree of insulin resistance in most neurodegenerative states. New data on the effects of salbutamol, an indirect anti‐TNF agent, on α‐synuclein and Parkinson's disease, APOE4 and tau add considerably to the rationale of the anti‐TNF approach to understanding, and treating, these diseases. Therapeutic advances being tested, and arguably useful for a number of the neurodegenerative diseases, include a reduction of excess cerebral TNF, whether directly, with a specific anti‐TNF biological agent such as etanercept via Batson's plexus, or indirectly via surgically implanting stem cells. Inhaled salbutamol also warrants investigating further across the neurodegenerative disease spectrum. It is now timely to integrate this range of new information across the neurodegenerative disease spectrum, rather than keep seeing it through the lens of individual disease states.
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Affiliation(s)
- I A Clark
- Research School of Biology, Australian National University, Canberra, Australia
| | - B Vissel
- Centre for Neuroscience and Regenerative Medicine, Faculty of Science, University of Technology, Sydney, NSW, Australia.,St. Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
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25
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Affiliation(s)
- Edward Tobinick
- a Institute of Neurological Recovery , Boca Raton , FL , USA
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26
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Affiliation(s)
- Ian A Clark
- a Research School of Biology , Australian National University , Canberra , Australia
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27
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Clark IA, Vissel B. Excess cerebral TNF causing glutamate excitotoxicity rationalizes treatment of neurodegenerative diseases and neurogenic pain by anti-TNF agents. J Neuroinflammation 2016; 13:236. [PMID: 27596607 PMCID: PMC5011997 DOI: 10.1186/s12974-016-0708-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/30/2016] [Indexed: 02/06/2023] Open
Abstract
The basic mechanism of the major neurodegenerative diseases, including neurogenic pain, needs to be agreed upon before rational treatments can be determined, but this knowledge is still in a state of flux. Most have agreed for decades that these disease states, both infectious and non-infectious, share arguments incriminating excitotoxicity induced by excessive extracellular cerebral glutamate. Excess cerebral levels of tumor necrosis factor (TNF) are also documented in the same group of disease states. However, no agreement exists on overarching mechanism for the harmful effects of excess TNF, nor, indeed how extracellular cerebral glutamate reaches toxic levels in these conditions. Here, we link the two, collecting and arguing the evidence that, across the range of neurodegenerative diseases, excessive TNF harms the central nervous system largely through causing extracellular glutamate to accumulate to levels high enough to inhibit synaptic activity or kill neurons and therefore their associated synapses as well. TNF can be predicted from the broader literature to cause this glutamate accumulation not only by increasing glutamate production by enhancing glutaminase, but in addition simultaneously reducing glutamate clearance by inhibiting re-uptake proteins. We also discuss the effects of a TNF receptor biological fusion protein (etanercept) and the indirect anti-TNF agents dithio-thalidomides, nilotinab, and cannabinoids on these neurological conditions. The therapeutic effects of 6-diazo-5-oxo-norleucine, ceptriaxone, and riluzole, agents unrelated to TNF but which either inhibit glutaminase or enhance re-uptake proteins, but do not do both, as would anti-TNF agents, are also discussed in this context. By pointing to excess extracellular glutamate as the target, these arguments greatly strengthen the case, put now for many years, to test appropriately delivered ant-TNF agents to treat neurodegenerative diseases in randomly controlled trials.
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Affiliation(s)
- Ian A Clark
- Biomedical Sciences and Biochemistry, Research School of Biology, Australian National University, Acton, Canberra, Australian Capital Territory, 0200, Australia.
| | - Bryce Vissel
- Neurodegeneration Research Group, Garvan Institute, 384 Victoria Street, Sydney, New South Wales, 2010, Australia
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28
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Brodtmann A, Kalra L. Experimental treatments for poststroke disability. Neurology 2016; 86:2122-3. [DOI: 10.1212/wnl.0000000000002750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Gronseth GS, Messé SR. Practice advisory: Etanercept for poststroke disability: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2016; 86:2208-11. [PMID: 27272034 DOI: 10.1212/wnl.0000000000002735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 12/30/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review evidence regarding the effectiveness, safety, and tolerability of etanercept used to treat patients with poststroke disability. METHODS We searched MEDLINE and the Cochrane Central Register of Controlled Trials for studies of adult patients with poststroke disability treated with etanercept in order to improve their functional status. We rated each study for risk of bias (Class I-IV) using the American Academy of Neurology therapeutic classification of evidence scheme. Practice recommendations were formulated on the basis of the strength of the evidence and assessments of potential benefits, potential harms, and patient preferences. RESULTS Two case series were identified, and both reported clinical improvements 3 weeks following treatment across a wide range of functional domains. However, both studies were rated Class IV because of poor methodologic quality (i.e., high risk of bias). CONCLUSIONS For patients with poststroke disability, the evidence is insufficient to support or refute a benefit of etanercept for the treatment of poststroke disability. RECOMMENDATIONS Clinicians should counsel patients considering etanercept for treatment of poststroke disability that the evidence is insufficient to determine the treatment's effectiveness and that it may be associated with adverse outcomes and high cost (Level U).
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Affiliation(s)
- Gary S Gronseth
- From the Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and the Department of Neurology (S.R.M.), University of Pennsylvania School of Medicine, Philadelphia
| | - Steven R Messé
- From the Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and the Department of Neurology (S.R.M.), University of Pennsylvania School of Medicine, Philadelphia
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Abstract
Perispinal injection is a novel emerging method of drug delivery to the central nervous system (CNS). Physiological barriers prevent macromolecules from efficiently penetrating into the CNS after systemic administration. Perispinal injection is designed to use the cerebrospinal venous system (CSVS) to enhance delivery of drugs to the CNS. It delivers a substance into the anatomic area posterior to the ligamentum flavum, an anatomic region drained by the external vertebral venous plexus (EVVP), a division of the CSVS. Blood within the EVVP communicates with the deeper venous plexuses of the CSVS. The anatomical basis for this method originates in the detailed studies of the CSVS published in 1819 by the French anatomist Gilbert Breschet. By the turn of the century, Breschet's findings were nearly forgotten, until rediscovered by American anatomist Oscar Batson in 1940. Batson confirmed the unique, linear, bidirectional and retrograde flow of blood between the spinal and cerebral divisions of the CSVS, made possible by the absence of venous valves. Recently, additional supporting evidence was discovered in the publications of American neurologist Corning. Analysis suggests that Corning's famous first use of cocaine for spinal anesthesia in 1885 was in fact based on Breschet's anatomical findings, and accomplished by perispinal injection. The therapeutic potential of perispinal injection for CNS disorders is highlighted by the rapid neurological improvement in patients with otherwise intractable neuroinflammatory disorders that may ensue following perispinal etanercept administration. Perispinal delivery merits intense investigation as a new method of enhanced delivery of macromolecules to the CNS and related structures.
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Affiliation(s)
- Edward Lewis Tobinick
- Institute of Neurological Recovery, 2300 Glades Road, Suite 305E, Boca Raton, FL, 33431, USA.
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A Neurologist's Guide to TNF Biology and to the Principles behind the Therapeutic Removal of Excess TNF in Disease. Neural Plast 2015. [PMID: 26221543 PMCID: PMC4510439 DOI: 10.1155/2015/358263] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Tumor necrosis factor (TNF) is an ancient and widespread cytokine required in small amounts for much physiological function. Higher concentrations are central to innate immunity, but if unchecked this cytokine orchestrates much chronic and acute disease, both infectious and noninfectious. While being a major proinflammatory cytokine, it also controls homeostasis and plasticity in physiological circumstances. For the last decade or so these principles have been shown to apply to the central nervous system as well as the rest of the body. Nevertheless, whereas this approach has been a major success in treating noncerebral disease, its investigation and potential widespread adoption in chronic neurological conditions has inexplicably stalled since the first open trial almost a decade ago. While neuroscience is closely involved with this approach, clinical neurology appears to be reticent in engaging with what it offers patients. Unfortunately, the basic biology of TNF and its relevance to disease is largely outside the traditions of neurology. The purpose of this review is to facilitate lowering communication barriers between the traditional anatomically based medical specialties through recognition of shared disease mechanisms and thus advance the prospects of a large group of patients with neurodegenerative conditions for whom at present little can be done.
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Perez-Polo JR, Rea HC, Johnson KM, Parsley MA, Unabia GC, Xu GY, Prough D, DeWitt DS, Paulucci-Holthauzen AA, Werrbach-Perez K, Hulsebosch CE. Inflammatory cytokine receptor blockade in a rodent model of mild traumatic brain injury. J Neurosci Res 2015; 94:27-38. [PMID: 26172557 DOI: 10.1002/jnr.23617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 05/24/2015] [Accepted: 06/15/2015] [Indexed: 12/14/2022]
Abstract
In rodent models of traumatic brain injury (TBI), both Interleukin-1β (IL-1β) and tumor necrosis factor-α (TNFα) levels increase early after injury to return later to basal levels. We have developed and characterized a rat mild fluid percussion model of TBI (mLFP injury) that results in righting reflex response times (RRRTs) that are less than those characteristic of moderate to severe LFP injury and yet increase IL-1α/β and TNFα levels. Here we report that blockade of IL-1α/β and TNFα binding to IL-1R and TNFR1, respectively, reduced neuropathology in parietal cortex, hippocampus, and thalamus and improved outcome. IL-1β binding to the type I IL-1 receptor (IL-1R1) can be blocked by a recombinant form of the endogenous IL-1R antagonist IL-1Ra (Kineret). TNFα binding to the TNF receptor (TNFR) can be blocked by the recombinant fusion protein etanercept, made up of a TNFR2 peptide fused to an Fc portion of human IgG1. There was no benefit from the combined blockades compared with individual blockades or after repeated treatments for 11 days after injury compared with one treatment at 1 hr after injury, when measured at 6 hr or 18 days, based on changes in neuropathology. There was also no further enhancement of blockade benefits after 18 days. Given that both Kineret and etanercept given singly or in combination showed similar beneficial effects and that TNFα also has a gliotransmitter role regulating AMPA receptor traffic, thus confounding effects of a TNFα blockade, we chose to focus on a single treatment with Kineret.
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Affiliation(s)
| | - H C Rea
- University of Texas Medical Branch, Galveston, Texas
| | - K M Johnson
- University of Texas Medical Branch, Galveston, Texas
| | - M A Parsley
- University of Texas Medical Branch, Galveston, Texas
| | - G C Unabia
- University of Texas Medical Branch, Galveston, Texas
| | - G-Y Xu
- University of Texas Medical Branch, Galveston, Texas
| | - D Prough
- University of Texas Medical Branch, Galveston, Texas
| | - D S DeWitt
- University of Texas Medical Branch, Galveston, Texas
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Tobinick E, Rodriguez-Romanacce H, Levine A, Ignatowski TA, Spengler RN. Immediate neurological recovery following perispinal etanercept years after brain injury. Clin Drug Investig 2015; 34:361-6. [PMID: 24647830 DOI: 10.1007/s40261-014-0186-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Positron emission tomographic brain imaging and pathological examination have revealed that a chronic, intracerebral neuroinflammatory response lasting for years after a single brain injury may occur in humans. Evidence suggests the immune signaling molecule, tumor necrosis factor (TNF), is centrally involved in this pathology through its modulation of microglial activation, role in synaptic dysfunction, and induction of depressive symptoms and neuropathic pain. Etanercept is a recombinant TNF receptor fusion protein and potent TNF inhibitor that has been found to reduce microglial activation and neuropathic pain in multiple experimental models. We report that a single dose of perispinal etanercept produced an immediate, profound, and sustained improvement in expressive aphasia, speech apraxia, and left hemiparesis in a patient with chronic, intractable, debilitating neurological dysfunction present for more than 3 years after acute brain injury. These results indicate that acute brain injury-induced pathologic levels of TNF may provide a therapeutic target that can be addressed years after injury. Perispinal administration of etanercept is capable of producing immediate relief from brain injury-mediated neurological dysfunction.
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Affiliation(s)
- Edward Tobinick
- Institute of Neurological Recovery, 2300 Glades Road Suite 305E, Boca Raton, FL, 33431, USA,
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34
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Clausen BH, Degn M, Martin NA, Couch Y, Karimi L, Ormhøj M, Mortensen MLB, Gredal HB, Gardiner C, Sargent IIL, Szymkowski DE, Petit GH, Deierborg T, Finsen B, Anthony DC, Lambertsen KL. Systemically administered anti-TNF therapy ameliorates functional outcomes after focal cerebral ischemia. J Neuroinflammation 2014; 11:203. [PMID: 25498129 PMCID: PMC4272527 DOI: 10.1186/s12974-014-0203-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 11/15/2014] [Indexed: 12/30/2022] Open
Abstract
Background The innate immune system contributes to the outcome after stroke, where neuroinflammation and post-stroke systemic immune depression are central features. Tumor necrosis factor (TNF), which exists in both a transmembrane (tm) and soluble (sol) form, is known to sustain complex inflammatory responses associated with stroke. We tested the effect of systemically blocking only solTNF versus blocking both tmTNF and solTNF on infarct volume, functional outcome and inflammation in focal cerebral ischemia. Methods We used XPro1595 (a dominant-negative inhibitor of solTNF) and etanercept (which blocks both solTNF and tmTNF) to test the effect of systemic administration on infarct volume, functional recovery and inflammation after focal cerebral ischemia in mice. Functional recovery was evaluated after one, three and five days, and infarct volumes at six hours, 24 hours and five days after ischemia. Brain inflammation, liver acute phase response (APR), spleen and blood leukocyte profiles, along with plasma microvesicle analysis, were evaluated. Results We found that both XPro1595 and etanercept significantly improved functional outcomes, altered microglial responses, and modified APR, spleen T cell and microvesicle numbers, but without affecting infarct volumes. Conclusions Our data suggest that XPro1595 and etanercept improve functional outcome after focal cerebral ischemia by altering the peripheral immune response, changing blood and spleen cell populations and decreasing granulocyte infiltration into the brain. Blocking solTNF, using XPro1595, was just as efficient as blocking both solTNF and tmTNF using etanercept. Our findings may have implications for future treatments with anti-TNF drugs in TNF-dependent diseases. Electronic supplementary material The online version of this article (doi:10.1186/s12974-014-0203-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bettina Hjelm Clausen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark.
| | - Matilda Degn
- Department of Diagnostics, Molecular Sleep Laboratory, Glostrup Hospital, Nordre Ringvej 69, 2600, Glostrup, Denmark.
| | - Nellie Anne Martin
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark.
| | - Yvonne Couch
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark. .,Department of Pharmacology, University of Oxford, Mansfield Road, OX1 3QT, Oxford, UK.
| | - Leena Karimi
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark.
| | - Maria Ormhøj
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark.
| | - Maria-Louise Bergholdt Mortensen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark.
| | - Hanne Birgit Gredal
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark. .,Department of Veterinary Clinical and Animal Sciences, Facuty of Health and Medical Sciences, University of Copenhagen, Dyrlægevej 16, 1870, Frederiksberg, Denmark.
| | - Chris Gardiner
- Nuffield Department of Obstetrics and Gynecology, University of Oxford, Headley Way, OX1 3QT, Oxford, UK.
| | - Ian I L Sargent
- Nuffield Department of Obstetrics and Gynecology, University of Oxford, Headley Way, OX1 3QT, Oxford, UK.
| | | | - Géraldine H Petit
- Department of Clinical Sciences, Laboratory for Experimental Medical Science, Neuronal Survival Unit, 22100 Lund University, BMC B11, Sölveg 19, Lund, Sweden.
| | - Tomas Deierborg
- Department of Clinical Sciences, Laboratory for Experimental Medical Science, Neuronal Survival Unit, 22100 Lund University, BMC B11, Sölveg 19, Lund, Sweden.
| | - Bente Finsen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark.
| | - Daniel Clive Anthony
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark. .,Department of Pharmacology, University of Oxford, Mansfield Road, OX1 3QT, Oxford, UK.
| | - Kate Lykke Lambertsen
- Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, st., 5000, Odense, Denmark.
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Ignatowski TA, Spengler RN, Tobinick E. Authors' reply to Whitlock: Perispinal etanercept for post-stroke neurological and cognitive dysfunction: scientific rationale and current evidence. CNS Drugs 2014; 28:1207-13. [PMID: 25373629 PMCID: PMC4246125 DOI: 10.1007/s40263-014-0212-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Tracey A. Ignatowski
- Department of Pathology and Anatomical Sciences and Program for Neuroscience, School of Medicine and Biomedical Sciences, The State University of New York, Buffalo, NY USA
| | | | - Edward Tobinick
- Institute of Neurological Recovery, 2300 Glades Road Suite 305E, Boca Raton, FL 33431 USA
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Tuttolomondo A, Pecoraro R, Pinto A. Studies of selective TNF inhibitors in the treatment of brain injury from stroke and trauma: a review of the evidence to date. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:2221-38. [PMID: 25422582 PMCID: PMC4232043 DOI: 10.2147/dddt.s67655] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The brain is very actively involved in immune-inflammatory processes, and the response to several trigger factors such as trauma, hemorrhage, or ischemia causes the release of active inflammatory substances such as cytokines, which are the basis of second-level damage. During brain ischemia and after brain trauma, the intrinsic inflammatory mechanisms of the brain, as well as those of the blood, are mediated by leukocytes that communicate with each other through cytokines. A neuroinflammatory cascade has been reported to be activated after a traumatic brain injury (TBI) and this cascade is due to the release of pro- and anti-inflammatory cytokines and chemokines. Microglia are the first sources of this inflammatory cascade in the brain setting. Also in an ischemic stroke setting, an important mediator of this inflammatory reaction is tumor necrosis factor (TNF)-α, which seems to be involved in every phase of stroke-related neuronal damage such as inflammatory and prothrombotic events. TNF-α has been shown to have an important role within the central nervous system; its properties include activation of microglia and astrocytes, influence on blood–brain barrier permeability, and influences on glutamatergic transmission and synaptic plasticity. TNF-α increases the amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor density on the cell surface and simultaneously decreases expression of γ-aminobutyric acid receptor cells, and these effects are related to a direct neurotoxic effect. Several endogenous mechanisms regulate TNF-α activity during inflammatory responses. Endogenous inhibitors of TNF include prostaglandins, cyclic adenosine monophosphate, and glucocorticoids. Etanercept, a biologic TNF antagonist, has a reported effect of decreasing microglia activation in experimental models, and it has been used therapeutically in animal models of ischemic and traumatic neuronal damage. In some studies using animal models, researchers have reported a limitation of TBI-induced cerebral ischemia due to etanercept action, amelioration of brain contusion signs, as well as motor and cognitive dysfunction. On this basis, it appears that etanercept may improve outcomes of TBI by penetrating into the cerebrospinal fluid in rats, although further studies in humans are needed to confirm these interesting and suggestive experimental findings.
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Affiliation(s)
- Antonino Tuttolomondo
- Biomedical Department of Internal and Specialistic Medicine, University of Palermo, Palermo, Italy
| | - Rosaria Pecoraro
- Biomedical Department of Internal and Specialistic Medicine, University of Palermo, Palermo, Italy
| | - Antonio Pinto
- Biomedical Department of Internal and Specialistic Medicine, University of Palermo, Palermo, Italy
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Abstract
There is increasing recognition of the involvement of the immune signaling molecule, tumor necrosis factor (TNF), in the pathophysiology of stroke and chronic brain dysfunction. TNF plays an important role both in modulating synaptic function and in the pathogenesis of neuropathic pain. Etanercept is a recombinant therapeutic that neutralizes pathologic levels of TNF. Brain imaging has demonstrated chronic intracerebral microglial activation and neuroinflammation following stroke and other forms of acute brain injury. Activated microglia release TNF, which mediates neurotoxicity in the stroke penumbra. Recent observational studies have reported rapid and sustained improvement in chronic post-stroke neurological and cognitive dysfunction following perispinal administration of etanercept. The biological plausibility of these results is supported by independent evidence demonstrating reduction in cognitive dysfunction, neuropathic pain, and microglial activation following the use of etanercept, as well as multiple studies reporting improvement in stroke outcome and cognitive impairment following therapeutic strategies designed to inhibit TNF. The causal association between etanercept treatment and reduction in post-stroke disability satisfy all of the Bradford Hill Criteria: strength of the association; consistency; specificity; temporality; biological gradient; biological plausibility; coherence; experimental evidence; and analogy. Recognition that chronic microglial activation and pathologic TNF concentration are targets that may be therapeutically addressed for years following stroke and other forms of acute brain injury provides an exciting new direction for research and treatment.
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38
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Selective TNF inhibition for chronic stroke and traumatic brain injury: an observational study involving 629 consecutive patients treated with perispinal etanercept. CNS Drugs 2013; 27:395-7. [PMID: 23580176 PMCID: PMC3668780 DOI: 10.1007/s40263-013-0057-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Tobinick E. Author's reply to Page: "Selective TNF inhibition for chronic stroke and traumatic brain injury: an observational study involving 629 consecutive patients treated with perispinal etanercept". CNS Drugs 2013; 27:399-402. [PMID: 23580177 DOI: 10.1007/s40263-013-0058-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Ian Clark
- Research School of Biology, Australian National University, Canberra, ACT 0200, Australia.
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Tobinick E, Kim NM, Reyzin G, Rodriguez-Romanacce H, DePuy V. Selective TNF inhibition for chronic stroke and traumatic brain injury: an observational study involving 629 consecutive patients treated with perispinal etanercept. CNS Drugs 2012; 26:1051-70. [PMID: 23100196 DOI: 10.1007/s40263-012-0013-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Brain injury from stroke and traumatic brain injury (TBI) may result in a persistent neuroinflammatory response in the injury penumbra. This response may include microglial activation and excess levels of tumour necrosis factor (TNF). Previous experimental data suggest that etanercept, a selective TNF inhibitor, has the ability to ameliorate microglial activation and modulate the adverse synaptic effects of excess TNF. Perispinal administration may enhance etanercept delivery across the blood-CSF barrier. OBJECTIVE The objective of this study was to systematically examine the clinical response following perispinal administration of etanercept in a cohort of patients with chronic neurological dysfunction after stroke and TBI. METHODS After approval by an independent external institutional review board (IRB), a chart review of all patients with chronic neurological dysfunction following stroke or TBI who were treated open-label with perispinal etanercept (PSE) from November 1, 2010 to July 14, 2012 at a group medical practice was performed. RESULTS The treated cohort included 629 consecutive patients. Charts of 617 patients following stroke and 12 patients following TBI were reviewed. The mean age of the stroke patients was 65.8 years ± 13.15 (range 13-97). The mean interval between treatment with PSE and stroke was 42.0 ± 57.84 months (range 0.5-419); for TBI the mean interval was 115.2 ± 160.22 months (range 4-537). Statistically significant improvements in motor impairment, spasticity, sensory impairment, cognition, psychological/behavioural function, aphasia and pain were noted in the stroke group, with a wide variety of additional clinical improvements noted in individuals, such as reductions in pseudobulbar affect and urinary incontinence. Improvements in multiple domains were typical. Significant improvement was noted irrespective of the length of time before treatment was initiated; there was evidence of a strong treatment effect even in the subgroup of patients treated more than 10 years after stroke and TBI. In the TBI cohort, motor impairment and spasticity were statistically significantly reduced. DISCUSSION Irrespective of the methodological limitations, the present results provide clinical evidence that stroke and TBI may lead to a persistent and ongoing neuroinflammatory response in the brain that is amenable to therapeutic intervention by selective inhibition of TNF, even years after the acute injury. CONCLUSION Excess TNF contributes to chronic neurological, neuropsychiatric and clinical impairment after stroke and TBI. Perispinal administration of etanercept produces clinical improvement in patients with chronic neurological dysfunction following stroke and TBI. The therapeutic window extends beyond a decade after stroke and TBI. Randomized clinical trials will be necessary to further quantify and characterize the clinical response.
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Affiliation(s)
- Edward Tobinick
- Institute of Neurological Recovery, 100 UCLA Medical Plaza, Suites 205-210, Los Angeles, CA 90095, USA.
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Clark I, Atwood C, Bowen R, Paz-Filho G, Vissel B. Tumor necrosis factor-induced cerebral insulin resistance in Alzheimer's disease links numerous treatment rationales. Pharmacol Rev 2012; 64:1004-26. [PMID: 22966039 DOI: 10.1124/pr.112.005850] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The evident limitations of the amyloid theory of the pathogenesis of Alzheimer's disease are increasingly putting alternatives in the spotlight. We argue here that a number of independently developing approaches to therapy-including specific and nonspecific anti-tumor necrosis factor (TNF) agents, apolipoprotein E mimetics, leptin, intranasal insulin, the glucagon-like peptide-1 mimetics and glycogen synthase kinase-3 (GSK-3) antagonists-are all part of an interlocking chain of events. All these approaches inform us that inflammation and thence cerebral insulin resistance constitute the pathway on which to focus for a successful clinical outcome in treating this disease. The key link in this chain presently absent is a recognition by Alzheimer's research community of the long-neglected history of TNF induction of insulin resistance. When this is incorporated into the bigger picture, it becomes evident that the interventions we discuss are not competing alternatives but equally valid approaches to correcting different parts of the same pathway to Alzheimer's disease. These treatments can be expected to be at least additive, and conceivably synergistic, in effect. Thus the inflammation, insulin resistance, GSK-3, and mitochondrial dysfunction hypotheses are not opposing ideas but stages of the same fundamental, overarching, pathway of Alzheimer's disease pathogenesis. The insight this provides into progenitor cells, including those involved in adult neurogenesis, is a key part of this approach. This pathway also has therapeutic implications for other circumstances in which brain TNF is pathologically increased, such as stroke, traumatic brain injury, and the infectious disease encephalopathies.
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Affiliation(s)
- Ian Clark
- Division of Medical Science and Biochemistry, Research School of Biology, Australian National University, Canberra ACT, Australia.
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Clark IA, Atwood CS. Is TNF a link between aging-related reproductive endocrine dyscrasia and Alzheimer's disease? J Alzheimers Dis 2012; 27:691-9. [PMID: 21891866 DOI: 10.3233/jad-2011-110887] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This commentary addresses a novel mechanism by which aging-related changes in reproductive hormones could mediate their action in the brain. It presents the evidence that dyotic endocrine signals modulate the expression of tumor necrosis factor (TNF) and related cytokines, and that these cytokines are a functionally important downstream link mediating neurodegeneration and dysfunction. This convergence of dyotic signaling on TNF-mediated degeneration and dysfunction has important implications for understanding the pathophysiology of AD, stroke, and traumatic brain disease, and also for the treatment of these diseases.
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Affiliation(s)
- Ian A Clark
- Research School of Biology, Australian National University, Canberra, ACT, Australia.
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Depression, strokes and dementia: new biological insights into an unfortunate pathway. Cardiovasc Psychiatry Neurol 2011; 2011:649629. [PMID: 22216404 PMCID: PMC3246693 DOI: 10.1155/2011/649629] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 10/14/2011] [Accepted: 10/18/2011] [Indexed: 01/12/2023] Open
Abstract
The literature emphasizes the risk of depression after a stroke. Less well known is the fact that depression may be as big a risk factor for strokes as hypertension, particularly in the older age group. This article reviews the risk for stroke and cognitive impairment consequent to depression, and describes the cardiovascular and immunological mechanisms that would appear to link depression to its cerebrovascular consequences. As well, the article refers to the brain imaging signatures that may allow prediction of impending brain injury. Finally, some questions that might be explored by future research are suggested, and some practical means to identify and help those at risk for the development of depression-associated vascular disease of the brain are suggested.
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Abstract
The seminal discovery that glial cells, particularly astrocytes, can release a number of gliotransmitters that serve as signalling molecules for the cross-talk with neighbouring cellular populations has recently changed our perception of brain functioning, as well as our view of the pathogenesis of several disorders of the CNS. Since glutamate was one of the first gliotransmitters to be identified and characterized, we tackle the mechanisms that underlie its release from astrocytes, including the Ca2+ signals underlying its efflux from astroglia, and we discuss the involvement of these events in a number of relevant physiological processes, from the modulatory control of neighbouring synapses to the regulation of blood supply to cerebral tissues. The relevance of these mechanisms strongly indicates that the contribution of glial cells and gliotransmission to the activities of the brain cannot be overlooked, and any study of CNS physiopathology needs to consider glial biology to have a comprehensive overview of brain function and dysfunction. Abnormalites in the signalling that controls the astrocytic release of glutamate are described in several experimental models of neurological disorders, for example, AIDS dementia complex, Alzheimer's disease and cerebral ischaemia. While the modalities of glutamate release from astrocytes remain poorly understood, and this represents a major impediment to the definition of novel therapeutic strategies targeting this process at the molecular level, some key mediators deputed to the control of the glial release of this excitatory amino acid have been identified. Among these, we can mention, for instance, proinflammatory cytokines, such as tumour necrosis factor-α, and prostaglandins. Agents that are able to block the major steps of tumour necrosis factor-α and prostaglandin production and/or signalling can be proposed as novel therapeutic targets for the treatment of these disorders.
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Affiliation(s)
- Daniela Rossi
- Laboratory for Research on Neurodegenerative Disorders, IRCCS Fondazione Salvatore Maugeri, Pavia, Italy.
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