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Keevil H, Phillips BE, England TJ. Remote ischemic conditioning for stroke: A critical systematic review. Int J Stroke 2024; 19:271-279. [PMID: 37466245 PMCID: PMC10903142 DOI: 10.1177/17474930231191082] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023]
Abstract
Remote ischemic conditioning (RIC) is the application of brief periods of ischemia to an organ or tissue with the aim of inducing protection from ischemia in a distant organ. It was first developed as a cardioprotective strategy but has been increasingly investigated as a neuroprotective intervention. The mechanisms by which RIC achieves neuroprotection are incompletely understood. Preclinical studies focus on the hypothesis that RIC can protect the brain from ischemia reperfusion (IR) injury following the restoration of blood flow after occlusion of a large cerebral artery. However, increasingly, a role of chronic RIC (CRIC) is being investigated as a means of promoting recovery following an ischemic insult to the brain. The recent publication of two large, randomized control trials has provided promise that RIC could improve functional outcomes after acute ischemic stroke, and that there may be a role for CRIC in the prevention of recurrent stroke. Although less developed, there is also proof-of-concept to suggest that RIC may be used to reduce vasospasm after subarachnoid hemorrhage or improve cognitive outcomes in vascular dementia. As a cheap, well-tolerated and almost universally applicable intervention, the motivation for investigating possible benefit of RIC in patients with cerebrovascular disease is great. In this review, we shall review the current evidence for RIC as applied to cerebrovascular disease.
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Affiliation(s)
- Harry Keevil
- Stroke Trials Unit, Division of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Ageing Research, and NIHR Nottingham Biomedical Research Centre, Division of Injury, Recovery & Inflammation Sciences, University of Nottingham, Nottingham, UK
| | - Bethan E Phillips
- Medical Research Council Versus Arthritis Centre for Musculoskeletal Ageing Research, and NIHR Nottingham Biomedical Research Centre, Division of Injury, Recovery & Inflammation Sciences, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Division of Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Stroke, University Hospitals of Derby and Burton, Derby, UK
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2
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Landman TRJ, Schoon Y, Warlé MC, Meijer FJA, Leeuw FED, Thijssen DHJ. The effect of repeated remote ischemic postconditioning after an ischemic stroke (REPOST): A randomized controlled trial. Int J Stroke 2023; 18:296-303. [PMID: 35593677 PMCID: PMC9941800 DOI: 10.1177/17474930221104710] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS A potential strategy to treat ischemic stroke may be the application of repeated remote ischemic postconditioning (rIPostC). This consists of several cycles of brief periods of limb ischemia followed by reperfusion, which can be applied by inflating a simple blood pressure cuff and subsequently could result in neuroprotection after stroke. METHODS Adult patients admitted with an ischemic stroke in the past 24 h were randomized 1:1 to repeated rIPostC or sham-conditioning. Repeated rIPostC was performed by inflating a blood pressure cuff around the upper arm (4 × 5 min at 200 mm Hg), which was repeated twice daily during hospitalization with a maximum of 4 days. Primary outcome was infarct size after 4 days or at discharge. Secondary outcomes included the modified Rankin Scale (mRS)-score after 12 weeks and the National Institutes of Health Stroke Scale (NIHSS) at discharge. RESULTS The trial was preliminarily stopped after we included 88 of the scheduled 180 patients (average age: 70 years, 68% male) into rIPostC (n = 40) and sham-conditioning (n = 48). Median infarct volume was 2.19 mL in rIPostC group and 5.90 mL in sham-conditioning, which was not significantly different between the two groups (median difference: 3.71; 95% CI: -0.56 to 6.09; p = 0.31). We found no significant shift in the mRS score distribution between groups. The adjusted common odds ratio was 2.09 (95% CI: 0.88-5.00). We found no significant difference in the NIHSS score between groups (median difference: 1.00; 95% CI: -0.99 to 1.40; p = 0.51). CONCLUSION This study found no significant improvement in infarct size or clinical outcome in patients with an acute ischemic stroke who were treated with repeated remote ischemic postconditioning. However, due to a lower-than-expected inclusion rate, no definitive conclusions about the effectiveness of rIPostC can be drawn.
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Affiliation(s)
- Thijs RJ Landman
- Department of Physiology, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands,Thijs RJ Landman, Department of Physiology,
Radboud Institute for Health Sciences, Radboud University Medical Center, Geert
Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands.
| | - Yvonne Schoon
- Department of Geriatric Medicine,
Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen,
The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Frederick JA Meijer
- Department of Medical Imaging, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Frank-Erik De Leeuw
- Donders Center for Medical
Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen,
The Netherlands
| | - Dick HJ Thijssen
- Department of Physiology, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands
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3
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Yu W, Ren C, Ji X. A review of remote ischemic conditioning as a potential strategy for neural repair poststroke. CNS Neurosci Ther 2022; 29:516-524. [PMID: 36550592 PMCID: PMC9873528 DOI: 10.1111/cns.14064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/17/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
Ischemic stroke is one of the major disabling health-care problem and multiple different approaches are needed to enhance rehabilitation, in which neural repair is the structural basement. Remote ischemic conditioning (RIC) is a strategy to trigger endogenous protect. RIC has been reported to play neuroprotective role in acute stage of stroke, but the effect of RIC on repair process remaining unclear. Several studies have discovered some overlapped mechanisms RIC and neural repair performs. This review provides a hypothesis that RIC is a potential therapeutic strategy on stroke rehabilitation by evaluating the existing evidence and puts forward some remaining questions to clarify and future researches to be performed in the field.
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Affiliation(s)
- Wantong Yu
- Department of Neurology and Beijing Key Laboratory of Hypoxia Translational MedicineXuanwu Hospital, Capital Medical UniversityBeijingChina
| | - Changhong Ren
- Department of Neurology and Beijing Key Laboratory of Hypoxia Translational MedicineXuanwu Hospital, Capital Medical UniversityBeijingChina,Center of Stroke, Beijing Institute for Brain DisorderCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Department of Neurology and Beijing Key Laboratory of Hypoxia Translational MedicineXuanwu Hospital, Capital Medical UniversityBeijingChina,Center of Stroke, Beijing Institute for Brain DisorderCapital Medical UniversityBeijingChina
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Tong Y, Lee H, Kohls W, Han Z, Duan H, Cheng Z, Li F, Gao J, Liu J, Geng X, Ding Y. Remote ischemic conditioning (RIC) with exercise (RICE) is safe and feasible for acute ischemic stroke (AIS) patients. Front Neurol 2022; 13:981498. [PMID: 36457864 PMCID: PMC9706098 DOI: 10.3389/fneur.2022.981498] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/31/2022] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVE Rehabilitation is essential in reducing stroke disability and should be performed as early as possible. Exercise is an established and effective rehabilitation method; however, its implementation has been limited as its very early use exacerbates cerebral injury and is restricted by patients' unstable conditions and disabilities. Remote ischemic conditioning (RIC) is a passive and accessible therapy in acute phases of stroke and appears to have similar neuroprotective effects as exercise. This study assessed the safety and feasibility of the novel rehabilitation strategy-early RIC followed by exercise (RICE) in acute ischemic stroke (AIS). METHODS We conducted a single-center, double-blinded, randomized controlled trial with AIS patients within 24 h of stroke onset or symptom exacerbation. All enrolled patients were randomly assigned, at a ratio of 1:1, to either the RICE group or the sham-RICE group (sham RIC with exercise). Each group received either RIC or sham RIC within 24 h after stroke onset or symptom exacerbation, once a day, for 14 days. Both groups started the exercise routine on day 4, twice daily, for 11 total days. The safety endpoints included clinical deterioration, recurrence of stroke, hemorrhagic transformation, complications, and adverse events resulting from RICE during hospitalization. The efficacy endpoints [Modified Rankin Scale (mRS) score, National Institutes of Health Stroke Scale (NIHSS) score, Barthel Index, and walking ability] were evaluated at admission and 90 days after stroke onset. RESULTS Forty AIS patients were recruited and completed the study. No significant differences in baseline characteristics were found between the two groups, which included risk factors, stroke severity at admission, pre-morbid disability, and other special treatments. No significant differences were found in the safety endpoints between two groups. Excellent recovery (mRS 0-2) at 3 months was obtained in 55% of the patients with RICE as compared 40% in sham group, but it did not reach a significant level. CONCLUSIONS RICE was safe and feasible for AIS patients, and seems to be a promising early stroke rehabilitation. The results of this study suggest a need for a future randomized and controlled multicenter trial with a larger sample size to determine the efficacy of RICE.
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Affiliation(s)
- Yanna Tong
- Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Hangil Lee
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
| | - Wesley Kohls
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
| | - Zhenzhen Han
- Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Honglian Duan
- Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zhe Cheng
- Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Fenghai Li
- Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jie Gao
- Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jing Liu
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
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Blanco S, Martínez-Lara E, Siles E, Peinado MÁ. New Strategies for Stroke Therapy: Nanoencapsulated Neuroglobin. Pharmaceutics 2022; 14:pharmaceutics14081737. [PMID: 36015363 PMCID: PMC9412405 DOI: 10.3390/pharmaceutics14081737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 01/12/2023] Open
Abstract
Stroke is a global health and socio-economic problem. However, no efficient preventive and/or palliative treatments have yet been found. Neuroglobin (Ngb) is an endogen neuroprotective protein, but it only exerts its beneficial action against stroke after increasing its basal levels. Therefore, its systemic administration appears to be an efficient therapy applicable to stroke and other neurodegenerative pathologies. Unfortunately, Ngb cannot cross the blood-brain barrier (BBB), making its direct pharmacological use unfeasible. Thus, the association of Ngb with a drug delivery system (DDS), such as nanoparticles (NPs), appears to be a good strategy for overcoming this handicap. NPs are a type of DDS which efficiently transport Ngb and increase its bioavailability in the infarcted area. Hence, we previously built hyaluronate NPS linked to Ngb (Ngb-NPs) as a therapeutic tool against stroke. This nanoformulation induced an improvement of the cerebral infarct prognosis. However, this innovative therapy is still in development, and a more in-depth study focusing on its long-lasting neuroprotectant and neuroregenerative capabilities is needed. In short, this review aims to update the state-of-the-art of stroke therapies based on Ngb, paying special attention to the use of nanotechnological drug-delivering tools.
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Li S, Yang Y, Li N, Li H, Xu J, Zhao W, Wang X, Ma L, Gao C, Ding Y, Ji X, Ren C. Limb Remote Ischemic Conditioning Promotes Neurogenesis after Cerebral Ischemia by Modulating miR-449b/Notch1 Pathway in Mice. Biomolecules 2022; 12:biom12081137. [PMID: 36009031 PMCID: PMC9405712 DOI: 10.3390/biom12081137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Neurogenesis plays an important role in the prognosis of stroke patients and is known to be promoted by the activation of the Notch1 signaling pathway. Studies on the airway epithelium have shown that miR-449b represses the Notch pathway. The study aimed to investigate whether limb remote ischemic conditioning (LRIC) was able to promote neurogenesis in cerebral ischemic mice, and to investigate the role of the miR-449b/Notch1 pathway in LRIC-induced neuroprotection. Male C57BL/6 mice (22–25 g) were subjected to transient middle cerebral artery occlusion (MCAO), and LRIC was performed in the bilateral lower limbs immediately after MCA occlusion. Immunofluorescence staining was performed to assess neurogenesis. The cell line NE-4C was used to elucidate the proliferation of neuronal stem cells in 8% O2. After LRIC treatment on day 28, mice recovered neurological function. Neuronal precursor proliferation was enhanced in the SVZ, and neuronal precursor migration was enhanced in the basal ganglia on day 7. LRIC promoted the improvement of neurological function in mice on day 28, promoted neuronal precursor proliferation in the SVZ, and enhanced neuronal precursor migration in the basal ganglia on day 7. The neurological function score was negatively correlated with the number of BrdU-positive/DCX-positive cells in the SVZ and striatum. LRIC promoted activated Notch1 protein expression in the SVZ and substantially downregulated miR-449b levels in the SVZ and plasma. In vitro, miR-449b was found to target Notch1. Lentivirus-mediated miR-449b knockdown increased Notch1 levels in NE-4C cells and increased proliferation in the cells. The effects of miR-449b inhibition on neurogenesis were ablated by the application of Notch1 shRNA. Our study showed that LRIC promoted the proliferation and migration of neural stem cells after MCAO, and these effects were modulated by the miR-449b/Notch1 pathway.
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Affiliation(s)
- Sijie Li
- Beijing Key Laboratory of Hypoxia Translational Medicine, Xuanwu Hospital, Center of Stroke, Beijing Institute of Brain Disorder, Capital Medical University, Beijing 100053, China
- Emergency Department, Xuan Wu Hospital, Capital Medical University, Beijing 100053, China
| | - Yong Yang
- School of Traditional Chinese Medicine, Beijing University of Chines Medicine, Beijing 100029, China
| | - Ning Li
- Beijing Key Laboratory of Hypoxia Translational Medicine, Xuanwu Hospital, Center of Stroke, Beijing Institute of Brain Disorder, Capital Medical University, Beijing 100053, China
| | - Haiyan Li
- Beijing Key Laboratory of Hypoxia Translational Medicine, Xuanwu Hospital, Center of Stroke, Beijing Institute of Brain Disorder, Capital Medical University, Beijing 100053, China
- School of Traditional Chinese Medicine, Beijing University of Chines Medicine, Beijing 100029, China
| | - Jiali Xu
- Beijing Key Laboratory of Hypoxia Translational Medicine, Xuanwu Hospital, Center of Stroke, Beijing Institute of Brain Disorder, Capital Medical University, Beijing 100053, China
| | - Wenbo Zhao
- Beijing Key Laboratory of Hypoxia Translational Medicine, Xuanwu Hospital, Center of Stroke, Beijing Institute of Brain Disorder, Capital Medical University, Beijing 100053, China
| | - Xiaojie Wang
- Department of Neurology, Shenzhen Qianhai Shekou Free Trade Zone Hospital, Shenzhen 518054, China
| | - Linqing Ma
- Department of Neurology, The People’s Hospital of Suzhou New District, Suzhou 215129, China
| | - Chen Gao
- Beijing Key Laboratory of Hypoxia Translational Medicine, Xuanwu Hospital, Center of Stroke, Beijing Institute of Brain Disorder, Capital Medical University, Beijing 100053, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxia Translational Medicine, Xuanwu Hospital, Center of Stroke, Beijing Institute of Brain Disorder, Capital Medical University, Beijing 100053, China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxia Translational Medicine, Xuanwu Hospital, Center of Stroke, Beijing Institute of Brain Disorder, Capital Medical University, Beijing 100053, China
- Correspondence: ; Tel.: +86-10-83198931; Fax: +86-10-63010085
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Ishizuka K, Hoshino T, Toi S, Mizuno T, Hosoya M, Saito M, Sato Y, Yagita Y, Todo K, Sakaguchi M, Ohashi T, Maruyama K, Hino S, Honma Y, Doijiri R, Yamagami H, Iguchi Y, Hirano T, Kimura K, Kitazono T, Kitagawa K. Remote ischemic conditioning for acute ischemic stroke part 2: Study protocol for a randomized controlled trial. Front Neurol 2022; 13:946431. [PMID: 36003294 PMCID: PMC9393485 DOI: 10.3389/fneur.2022.946431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background Remote ischemic conditioning (RIC) refers to the application of repeated short periods of ischemia intended to protect remote areas against tissue damage during and after prolonged ischemia. Aim We aim to evaluate the efficacy of RIC, determined by the modified Rankin Scale (mRS) score at 90 days after stroke onset. Design and methods This study is an investigator-initiated, multicenter, prospective, randomized, open-label, parallel-group clinical trial. The sample size is 400, comprising 200 patients who will receive RIC and 200 controls. The patients will be divided into three groups according to their National Institutes of Health Stroke Scale score at enrollment: 5–9, mild; 10–14, moderate; 15–20, severe. The RIC protocol will be comprised of four cycles, each consisting of 5 min of blood pressure cuff inflation (at 200 mmHg or 50 mmHg above the systolic blood pressure) followed by 5 min of reperfusion, with the cuff placed on the thigh on the unaffected side. The control group will only undergo blood pressure measurements before and after the intervention period. This trial is registered with the UMIN Clinical Trial Registry (https://www.umin.ac.jp/: UMIN000046225). Study outcome The primary outcome will be a good functional outcome as determined by the mRS score at 90 days after stroke onset, with a target mRS score of 0–1 in the mild group, 0–2 in the moderate group, and 0–3 in the severe group. Discussion This trial may help determine whether RIC should be recommended as a routine clinical strategy for patients with ischemic stroke.
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Affiliation(s)
- Kentaro Ishizuka
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
- *Correspondence: Kentaro Ishizuka
| | - Takao Hoshino
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Sono Toi
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takafumi Mizuno
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Megumi Hosoya
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Moeko Saito
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yasuto Sato
- Department of Public Health, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Manabu Sakaguchi
- Department of Neurology, Osaka General Medical Center, Osaka, Japan
| | - Takashi Ohashi
- Department of Neurology, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Kenji Maruyama
- Department of Neurology, Toda Chuo General Hospital, Saitama, Japan
| | - Shuji Hino
- Department of Neurology, Saitama Red Cross Hospital, Saitama, Japan
| | - Yutaka Honma
- Department of Neurology, Showa General Hospital, Tokyo, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
- Kazuo Kitagawa
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Zheng T, Lai X, Lu J, Chen Q, Wei D. Three Dimensional-Arterial Spin Labeling Evaluation of Improved Cerebral Perfusion After Limb Remote Ischemic Preconditioning in a Rat Model of Focal Ischemic Stroke. Front Neuroanat 2022; 16:893953. [PMID: 35847828 PMCID: PMC9280338 DOI: 10.3389/fnana.2022.893953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the application value of 3D arterial spin labeling (3D-ASL) for evaluating distal limb ischemic preconditioning to improve acute ischemic stroke (AIS) perfusion. Materials and Methods A total of 40 patients with AISs treated in our hospital from January 2020 to December 2020 were recruited, and 15 healthy individuals who were examined in our hospital during the same period were included as the control group; all of these participants were scored on the National Institutes of Health Stroke Scale (NIHSS) and examined by MRI. Sequences included conventional sequences, diffusion-weighted imaging (DWI), magnetic resonance angiography (MRA), and 3D-ASL, and cerebral infarct volume and cerebral blood flow (CBF) in the area of the infarct lesion were measured. After 3 months of treatment, patients with AIS were scored on the modified Rankin Scale (mRS) and divided into good prognosis and poor prognosis groups. In total, 55 adult male Sprague–Dawley rats were divided randomly into three groups: 20 in the middle cerebral artery occlusion (MCAO) group, 20 in the MCAO + limb remote ischemic preconditioning (LRP) group, and 15 in the sham group. In total, 48 h after the procedures, conventional MRI, DWI, and 3D-ASL sequence data were collected, and 2,3,5-trphenyltetrazolium chloride monohydrate (TTC) staining and behavioral scoring were performed. CBF was recorded in the infarct lesion area and the corresponding contralateral area, and the affected/contralateral relative values (rCBF) were calculated to compare the differences in rCBF between different groups. The pathological changes in brain tissues were observed by HE staining, and the expression of vascular endothelial growth factor (VEGF) and platelet endothelial cell adhesion molecule-1 (PECAM-1/CD31) in brain tissues was detected by immunofluorescence and real-time quantitative polymerase chain reaction (RT-qPCR). The protein expression of VEGF was detected by western blotting. Results Hypertension and internal carotid atherosclerosis are high-risk factors for ischemic stroke, and CBF values in the infarct area are significantly lower than those in the corresponding areas on the contralateral side. NIHSS and mRS scores and CBF values have higher specificity and sensitivity for the prognosis of patients with AIS. LRP significantly reduces the infarct area, improves behavioral deficits in rats with cerebral ischemia, reduces neurological injury and histological damage, protects vascular structures, and promotes neovascularization. In addition, 3D-ASL showed a significant increase in brain tissue perfusion in the ischemic area after LRP, and the expression of VEGF and CD31 showed a significant positive correlation with CBF values. Conclusion Three dimensional (3D) ASL can be used to evaluate LRP to improve stroke perfusion, and its protective effect may be closely related to LRP-induced vascular regeneration.
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Affiliation(s)
- Tianxiu Zheng
- Department of Radiology, Ningde Municipal Hospital Affiliated to Ningde Normal University, Ningde, China
| | - Xiaolan Lai
- Department of Hematology, Ningde Municipal Hospital Affiliated to Ningde Normal University, Ningde, China
| | - Jiaojiao Lu
- Department of Central Laboratory, Ningde Municipal Hospital Affiliated to Ningde Normal University, Ningde, China
| | - Qiuyan Chen
- Department of Radiology, Ningde Municipal Hospital Affiliated to Ningde Normal University, Ningde, China
| | - Dingtai Wei
- Department of Radiology, Ningde Municipal Hospital Affiliated to Ningde Normal University, Ningde, China
- *Correspondence: Dingtai Wei,
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9
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Peinado MÁ, Ovelleiro D, del Moral ML, Hernández R, Martínez-Lara E, Siles E, Pedrajas JR, García-Martín ML, Caro C, Peralta S, Morales ME, Ruiz MA, Blanco S. Biological Implications of a Stroke Therapy Based in Neuroglobin Hyaluronate Nanoparticles. Neuroprotective Role and Molecular Bases. Int J Mol Sci 2021; 23:247. [PMID: 35008673 PMCID: PMC8745106 DOI: 10.3390/ijms23010247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 12/23/2021] [Indexed: 12/11/2022] Open
Abstract
Exogenous neuroprotective protein neuroglobin (Ngb) cannot cross the blood-brain barrier. To overcome this difficulty, we synthesized hyaluronate nanoparticles (NPs), able to deliver Ngb into the brain in an animal model of stroke (MCAO). These NPs effectively reached neurons, and were microscopically identified after 24 h of reperfusion. Compared to MCAO non-treated animals, those treated with Ngb-NPs showed survival rates up to 50% higher, and better neurological scores. Tissue damage improved with the treatment, but no changes in the infarct volume or in the oxidative/nitrosative values were detected. A proteomics approach (p-value < 0.02; fold change = 0.05) in the infarcted areas showed a total of 219 proteins that significantly changed their expression after stroke and treatment with Ngb-NPs. Of special interest, are proteins such as FBXO7 and NTRK2, which were downexpressed in stroke, but overexpressed after treatment with Ngb-NPs; and ATX2L, which was overexpressed only under the effect of Ngb. Interestingly, the proteins affected by the treatment with Ngb were involved in mitochondrial function and cell death, endocytosis, protein metabolism, cytoskeletal remodeling, or synaptic function, and in regenerative processes, such as dendritogenesis, neuritogenesis, or sinaptogenesis. Consequently, our pharmaceutical preparation may open new therapeutic scopes for stroke and possibly for other neurodegenerative pathologies.
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Affiliation(s)
- María Ángeles Peinado
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - David Ovelleiro
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - María Luisa del Moral
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - Raquel Hernández
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - Esther Martínez-Lara
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - Eva Siles
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - José Rafael Pedrajas
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - María Luisa García-Martín
- BIONAND-Centro Andaluz de Nanomedicina y Biotecnología, Junta de Andalucía, Universidad de Málaga, Parque Tecnológico de Andalucía, 29590 Malaga, Spain; (M.L.G.-M.); (C.C.)
| | - Carlos Caro
- BIONAND-Centro Andaluz de Nanomedicina y Biotecnología, Junta de Andalucía, Universidad de Málaga, Parque Tecnológico de Andalucía, 29590 Malaga, Spain; (M.L.G.-M.); (C.C.)
| | - Sebastián Peralta
- Department of Pharmacy and Pharmaceutical Technology, Campus de Cartuja s/n, School of Pharmacy, University of Granada, 18071 Granada, Spain; (S.P.); (M.E.M.); (M.A.R.)
| | - María Encarnación Morales
- Department of Pharmacy and Pharmaceutical Technology, Campus de Cartuja s/n, School of Pharmacy, University of Granada, 18071 Granada, Spain; (S.P.); (M.E.M.); (M.A.R.)
| | - María Adolfina Ruiz
- Department of Pharmacy and Pharmaceutical Technology, Campus de Cartuja s/n, School of Pharmacy, University of Granada, 18071 Granada, Spain; (S.P.); (M.E.M.); (M.A.R.)
| | - Santos Blanco
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
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10
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Dias-Pedroso D, Ramalho JS, Sardão VA, Jones JG, Romão CC, Oliveira PJ, Vieira HLA. Carbon Monoxide-Neuroglobin Axis Targeting Metabolism Against Inflammation in BV-2 Microglial Cells. Mol Neurobiol 2021; 59:916-931. [PMID: 34797521 DOI: 10.1007/s12035-021-02630-4] [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: 08/26/2021] [Accepted: 10/29/2021] [Indexed: 01/06/2023]
Abstract
Microglia are the immune competent cell of the central nervous system (CNS), promoting brain homeostasis and regulating inflammatory response against infection and injury. Chronic or exacerbated neuroinflammation is a cause of damage in several brain pathologies. Endogenous carbon monoxide (CO), produced from the degradation of heme, is described as anti-apoptotic and anti-inflammatory in several contexts, including in the CNS. Neuroglobin (Ngb) is a haemoglobin-homologous protein, which upregulation triggers antioxidant defence and prevents neuronal apoptosis. Thus, we hypothesised a crosstalk between CO and Ngb, in particular, that the anti-neuroinflammatory role of CO in microglia depends on Ngb. A novel CO-releasing molecule (ALF826) based on molybdenum was used for delivering CO in microglial culture.BV-2 mouse microglial cell line was challenged with lipopolysaccharide (LPS) for triggering inflammation, and after 6 h ALF826 was added. CO exposure limited inflammation by decreasing inducible nitric oxide synthase (iNOS) expression and the production of nitric oxide (NO) and tumour necrosis factor-α (TNF-α), and by increasing interleukine-10 (IL-10) release. CO-induced Ngb upregulation correlated in time with CO's anti-inflammatory effect. Moreover, knocking down Ngb reversed the anti-inflammatory effect of CO, suggesting that dependents on Ngb expression. CO-induced Ngb upregulation was independent on ROS signalling, but partially dependent on the transcriptional factor SP1. Finally, microglial cell metabolism is also involved in the inflammatory response. In fact, LPS treatment decreased oxygen consumption in microglia, indicating a switch to glycolysis, which is associated with a proinflammatory. While CO treatment increased oxygen consumption, reverting LPS effect and indicating a metabolic shift into a more oxidative metabolism. Moreover, in the absence of Ngb, this phenotype was no longer observed, indicating Ngb is needed for CO's modulation of microglial metabolism. Finally, the metabolic shift induced by CO did not depend on alteration of mitochondrial population. In conclusion, neuroglobin emerges for the first time as a key player for CO signalling against exacerbated inflammation in microglia.
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Affiliation(s)
| | - José S Ramalho
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Vilma A Sardão
- CNC-Center for Neuroscience and Cell Biology, CIBB - Centre for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal
| | - John G Jones
- CNC-Center for Neuroscience and Cell Biology, CIBB - Centre for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal
| | - Carlos C Romão
- Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Oeiras, Portugal
| | - Paulo J Oliveira
- CNC-Center for Neuroscience and Cell Biology, CIBB - Centre for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal
| | - Helena L A Vieira
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal. .,UCIBIO, Applied Molecular Biosciences Unit, Department of Chemistry, Faculdade de Ciências e Tecnologia, NOVA School of Science and Technology, Universidade Nova de Lisboa, Campus de Caparica, 2829-526, Caparica, Portugal. .,Associate Laboratory i4HB - Institute for Health and Bioeconomy, NOVA School of Science and Technology, Universidade Nova de Lisboa, Caparica, Portugal.
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11
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Mollet I, Marto JP, Mendonça M, Baptista MV, Vieira HLA. Remote but not Distant: a Review on Experimental Models and Clinical Trials in Remote Ischemic Conditioning as Potential Therapy in Ischemic Stroke. Mol Neurobiol 2021; 59:294-325. [PMID: 34686988 PMCID: PMC8533672 DOI: 10.1007/s12035-021-02585-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/29/2021] [Indexed: 12/19/2022]
Abstract
Stroke is one of the main causes of neurological disability worldwide and the second cause of death in people over 65 years old, resulting in great economic and social burden. Ischemic stroke accounts for 85% of total cases, and the approved therapies are based on re-establishment of blood flow, and do not directly target brain parenchyma. Thus, novel therapies are urgently needed. In this review, limb remote ischemic conditioning (RIC) is revised and discussed as a potential therapy against ischemic stroke. The review targets both (i) fundamental research based on experimental models and (ii) clinical research based on clinical trials and human interventional studies with healthy volunteers. Moreover, it also presents two approaches concerning RIC mechanisms in stroke: (i) description of the underlying cerebral cellular and molecular mechanisms triggered by limb RIC that promote neuroprotection against stroke induced damage and (ii) the identification of signaling factors involved in inter-organ communication following RIC procedure. Limb to brain remote signaling can occur via circulating biochemical factors, immune cells, and/or stimulation of autonomic nervous system. In this review, these three hypotheses are explored in both humans and experimental models. Finally, the challenges involved in translating experimentally generated scientific knowledge to a clinical setting are also discussed.
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Affiliation(s)
- Inês Mollet
- UCIBIO, Applied Molecular Biosciences Unit, Department of Chemistry, NOVA School of Science and Technology, Universidade NOVA de Lisboa, Campus de Caparica, 2829-526, Caparica, Portugal.,CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - João Pedro Marto
- CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal.,Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Marcelo Mendonça
- CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal.,Champalimaud Research, Champalimaud Center for the Unknown, Lisbon, Portugal
| | - Miguel Viana Baptista
- CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal.,Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Helena L A Vieira
- UCIBIO, Applied Molecular Biosciences Unit, Department of Chemistry, NOVA School of Science and Technology, Universidade NOVA de Lisboa, Campus de Caparica, 2829-526, Caparica, Portugal. .,CEDOC, Faculdade de Ciências Médicas/NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal. .,Associate Laboratory i4HB - Institute for Health and Bioeconomy, NOVA School of Science and Technology, NOVA University Lisbon, Caparica, Portugal.
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12
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Lee H, Yun HJ, Ding Y. Timing is everything: Exercise therapy and remote ischemic conditioning for acute ischemic stroke patients. Brain Circ 2021; 7:178-186. [PMID: 34667901 PMCID: PMC8459690 DOI: 10.4103/bc.bc_35_21] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/02/2021] [Accepted: 06/21/2021] [Indexed: 12/15/2022] Open
Abstract
Physical exercise is a promising rehabilitative strategy for acute ischemic stroke. Preclinical trials suggest that exercise restores cerebral blood circulation and re-establishes the blood–brain barrier’s integrity with neurological function and motor skill improvement. Clinical trials demonstrated that exercise improves prognosis and decreases complications after ischemic events. Due to these encouraging findings, early exercise rehabilitation has been quickly adopted into stroke rehabilitation guidelines. Unfortunately, preclinical trials have failed to warn us of an adverse effect. Trials with very early exercise rehabilitation (within 24 h of ischemic attack) found an inferior prognosis at 3 months. It was not immediately clear as to why exercise was detrimental when performed very early while it was ameliorative just a few short days later. This review aimed to explore the potential mechanisms of harm seen in very early exercise administered to acute ischemic stroke patients. To begin, the mechanisms of exercise’s benefit were transposed onto the current understanding of acute ischemic stroke’s pathogenesis, specifically during the acute and subacute phases. Then, exercise rehabilitation’s mechanisms were compared to that of remote ischemic conditioning (RIC). This comparison may reveal how RIC may be providing clinical benefit during the acute phase of ischemic stroke when exercise proved to be harmful.
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Affiliation(s)
- Hangil Lee
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ho Jun Yun
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA.,Department of Research and Development Center, John D. Dingell VA Medical Center, Detroit, Michigan, USA
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13
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Hansen LF, Nielsen NSK, Christoffersen LC, Kruuse C. Translational challenges of remote ischemic conditioning in ischemic stroke - a systematic review. Ann Clin Transl Neurol 2021; 8:1720-1729. [PMID: 34133841 PMCID: PMC8351389 DOI: 10.1002/acn3.51405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/20/2021] [Accepted: 05/19/2021] [Indexed: 12/27/2022] Open
Abstract
Remote ischemic conditioning (RIC) has well‐established cardioprotective effects in preclinical studies and promising results in preclinical stroke research. Effective translation from preclinical studies to clinical trials has yet to be accomplished, perhaps because of the use of multiple applications of RIC (e.g., pre‐, per‐, or post‐conditioning) in preclinical studies by both invasive and non‐invasive protocols, some of which not clinically applicable. Our systematic review conformed to PRISMA guidelines and addressed differences in clinically relevant RIC applications and outcomes between preclinical and clinical studies. We retrieved a total of 30 studies (8 human; 22 animal) that met the inclusion criteria of testing clinically relevant procedures; namely, non‐invasive and per‐ or post‐conditioning protocols. Per‐conditioning was applied in 6 animal and 3 human studies, post‐conditioning was applied in 16 animal and 5 human studies, and both conditioning methods were applied in 2 animal studies. Application of RIC varied between human and animal studies regarding initiation, duration, repetition, and number of limbs included. Study designs did not systematically apply blinding, randomization, or placebo controls. On only a few occasions did preclinical studies include animals with clinically relevant comorbidities. Clinical trials were challenged by not completing the intended number of RIC cycles or addressing this deficit in the data analysis. Consistency and transferability of methods used for positive animal studies and subsequent human studies are essential for the optimal translation of results. Consensus on preclinical and clinical RIC procedures should be reached for a full understanding of the possible beneficial effects of RIC treatment in stroke.
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Affiliation(s)
- Line Fuglsang Hansen
- Department of Neurology, Neurovascular Research Unit, Herlev Gentofte Hospital, Copenhagen, Denmark.,Department of Anesthesiology and Intensive Care, Holbaek Hospital, Holbaek, Denmark
| | - Nicholine S K Nielsen
- Department of Neurology, Neurovascular Research Unit, Herlev Gentofte Hospital, Copenhagen, Denmark
| | | | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Herlev Gentofte Hospital, Copenhagen, Denmark.,Department. of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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14
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Pico F, Lapergue B, Ferrigno M, Rosso C, Meseguer E, Chadenat ML, Bourdain F, Obadia M, Hirel C, Duong DL, Deltour S, Aegerter P, Labreuche J, Cattenoy A, Smadja D, Hosseini H, Guillon B, Wolff V, Samson Y, Cordonnier C, Amarenco P. Effect of In-Hospital Remote Ischemic Perconditioning on Brain Infarction Growth and Clinical Outcomes in Patients With Acute Ischemic Stroke: The RESCUE BRAIN Randomized Clinical Trial. JAMA Neurol 2021; 77:725-734. [PMID: 32227157 DOI: 10.1001/jamaneurol.2020.0326] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Treatment with remote ischemic perconditioning has been reported to reduce brain infarction volume in animal models of stroke. Whether this neuroprotective effect was observed in patients with acute ischemic stroke remains unknown. Objective To determine whether treatment with remote ischemic perconditioning administered to the leg of patients with acute ischemic stroke can reduce brain infarction volume growth. Design, Setting, and Participants This proof-of-concept multicenter prospective randomized open-label with blinded end point clinical trial was performed from January 12, 2015, to May 2, 2018. Patients were recruited from 11 stroke centers in France. Of the 188 patients who received magnetic resonance imaging within 6 hours of symptom onset and were confirmed to have carotid ischemic stroke, 93 were randomized to receive treatment with lower-limb remote ischemic perconditioning in addition to standard care (the intervention group), and 95 were randomized to receive standard care alone (the control group). Interventions Randomization on a 1:1 ratio to receive treatment with remote ischemic perconditioning (4 cycles of 5-minute inflations and 5-minute deflations to the thigh to 110 mm Hg above systolic blood pressure) in addition to standard care or standard care alone. Main Outcomes and Measures The change in brain infarction volume growth between baseline and 24 hours, measured by a diffusion-weighted sequence of magnetic resonance imaging scans of the brain. Results A total of 188 patients (mean [SD] age, 67.2 [15.7] years; 98 men [52.1%]) were included in this intention-to-treat analysis. At hospital admission, the median National Institutes of Health Stroke Scale score was 10 (interquartile range [IQR], 6-16) and the median brain infarction volume was 11.4 cm3 (IQR, 3.6-35.8 cm3); 164 patients (87.2%) received intravenous thrombolysis, and 64 patients (34.0%) underwent mechanical thrombectomy. The median increase in brain infarction growth was 0.30 cm3 (IQR, 0.11-0.48 cm3) in the intervention group and 0.37 cm3 (IQR, 0.19-0.55 cm3) in the control group (mean between-group difference on loge-transformed change, -0.07; 95% CI, -0.33 to 0.18; P = .57). An excellent outcome (defined as a score of 0-1 on the 90-day modified Rankin Scale or a score equal to the prestroke modified Rankin Scale score) was observed in 46 of 90 patients (51.1%) in the intervention group and 37 of 91 patients (40.7%) in the control group (P = .12). No significant differences in 90-day mortality were observed between the intervention and control groups (14 of 90 patients; Kaplan-Meier estimate, 15.8% vs 10 of 91 patients; Kaplan-Meier estimate, 10.4%, respectively; P = .45) or with symptomatic intracerebral hemorrhage (4 of 88 patients [4.5%] in both groups; P = .97). Conclusions and Relevance In this study, treatment with remote ischemic perconditioning, during or after reperfusion therapies, had no significant effect on brain infarction volume growth at 24 hours after symptom onset. Trial Registration ClinicalTrials.gov Identifier: NCT02189928.
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Affiliation(s)
- Fernando Pico
- Department of Neurology and Stroke Center, Versailles Mignot Hospital, Versailles, France.,University of Versailles Saint-Quentin-en-Yvelines and Paris-Saclay University, Saint-Aubin, France.,Laboratoire de Recherche Vasculaire Translationnelle, Inserm U1148, Paris, France
| | - Bertrand Lapergue
- University of Versailles Saint-Quentin-en-Yvelines and Paris-Saclay University, Saint-Aubin, France.,Neurology and Stroke Center, Hôpital Foch, Suresnes, France
| | - Marc Ferrigno
- Department of Degenerative and Vascular Cognitive Disorders, Inserm U1171, Université de Lille, Lille, France.,Department of Neurology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Charlotte Rosso
- Assistance Publique-Hopitaux de Paris, Service des Urgences Cerebro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France.,Centre National de la Recherche Scientifique, Inserm U1127, Unite Mixte de Recherche 7225, Institut du Cerveau et de la Moelle Epiniere, Sorbonne Universite, Paris, France
| | - Elena Meseguer
- Assistance Publique-Hôpitaux de Paris, Department of Neurology and Stroke Center, Bichat University Hospital, Universite Paris Diderot, Sorbonne Cite, Paris, France
| | - Marie-Laure Chadenat
- Department of Neurology and Stroke Center, Versailles Mignot Hospital, Versailles, France
| | | | - Michael Obadia
- Neurology and Stroke Center, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Catherine Hirel
- Department of Neurology and Stroke Center, Versailles Mignot Hospital, Versailles, France.,University of Versailles Saint-Quentin-en-Yvelines and Paris-Saclay University, Saint-Aubin, France
| | - Duc Long Duong
- Department of Neurology and Stroke Center, Versailles Mignot Hospital, Versailles, France
| | - Sandrine Deltour
- Assistance Publique-Hopitaux de Paris, Service des Urgences Cerebro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Philippe Aegerter
- Assistance Publique-Hôpitaux de Paris, Vieillissement et Maladies Chroniques, IndianaSERM, Unité Mixte de Recherche 1168, Universite de Versailles Saint-Quentin-en-Yvelines, Versailles, France.,Department of Biostatistics, Université de Lille, Lille, France
| | - Julien Labreuche
- Unité de Recherche EA 2694-Sante Publique: Epidemiologie et Qualite des Soins, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Amina Cattenoy
- Délégation à la Recherche Clinique, Versailles Mignot Hospital, Versailles, France
| | - Didier Smadja
- Stroke Unit, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Hassan Hosseini
- Assistance Publique-Hopitaux de Paris, Stroke Center, Henri Mondor Hospital, Université Paris-Est Créteil, Creteil, France
| | - Benoit Guillon
- Department of Neurology, University Hospital of Nantes, Nantes, France
| | - Valérie Wolff
- Stroke Unit, Strasbourg University Hospital, Strasbourg, France
| | - Yves Samson
- Assistance Publique-Hopitaux de Paris, Service des Urgences Cerebro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - Charlotte Cordonnier
- Department of Degenerative and Vascular Cognitive Disorders, Inserm U1171, Université de Lille, Lille, France.,Department of Neurology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Pierre Amarenco
- Laboratoire de Recherche Vasculaire Translationnelle, Inserm U1148, Paris, France.,Assistance Publique-Hôpitaux de Paris, Department of Neurology and Stroke Center, Bichat University Hospital, Universite Paris Diderot, Sorbonne Cite, Paris, France
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15
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Weir P, Maguire R, O'Sullivan SE, England TJ. A meta-analysis of remote ischaemic conditioning in experimental stroke. J Cereb Blood Flow Metab 2021; 41:3-13. [PMID: 32538284 PMCID: PMC7747156 DOI: 10.1177/0271678x20924077] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Remote ischaemic conditioning (RIC) is achieved by repeated transient ischaemia of a distant organ/limb and is neuroprotective in experimental ischaemic stroke. However, the optimal time and methods of administration are unclear. Systematic review identified relevant preclinical studies; two authors independently extracted data on infarct volume, neurological deficit, RIC method (administration time, site, cycle number, length of limb occlusion (dose)), species and quality. Data were analysed using random effects models; results expressed as standardised mean difference (SMD). In 57 publications incorporating 99 experiments (1406 rats, 101 mice, 14 monkeys), RIC reduced lesion volume in transient (SMD -2.0; 95% CI -2.38, -1.61; p < 0.00001) and permanent (SMD -1.54; 95% CI -2.38, -1.61; p < 0.00001) focal models of ischaemia and improved neurological deficit (SMD -1.63; 95% CI -1.97, -1.29, p < 0.00001). In meta-regression, cycle length and number, dose and limb number did not interact with infarct volume, although country and physiological monitoring during anaesthesia did. In all studies, RIC was ineffective if the dose was <10 or ≥50 min. Median study quality was 7 (range 4-9/10); Egger's test suggested publication bias (p < 0.001). RIC is most effective in experimental stroke using a dose between 10 and 45 min. Further studies using repeated dosing in animals with co-morbidities are warranted.
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Affiliation(s)
- Philippa Weir
- Vascular Medicine, Division of Medical Sciences and GEM, School of Medicine, University of Nottingham, Derby, UK
| | - Ryan Maguire
- Vascular Medicine, Division of Medical Sciences and GEM, School of Medicine, University of Nottingham, Derby, UK
| | - Saoirse E O'Sullivan
- Vascular Medicine, Division of Medical Sciences and GEM, School of Medicine, University of Nottingham, Derby, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences and GEM, School of Medicine, University of Nottingham, Derby, UK.,University Hospitals of Derby and Burton NHS Foundation Trust, Royal Derby Hospital, Derby, UK
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16
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Purroy F, García C, Mauri G, Pereira C, Torres C, Vazquez-Justes D, Vicente-Pascual M, Vena A, Arque G. Induced neuroprotection by remote ischemic perconditioning as a new paradigm in ischemic stroke at the acute phase, a systematic review. BMC Neurol 2020; 20:266. [PMID: 32615939 PMCID: PMC7330956 DOI: 10.1186/s12883-020-01836-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/22/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Remote ischemic conditioning during cerebral ischemia (remote ischemic perconditioning, RIPerC) refers to the application of several cycles of brief ischemia and reperfusion (I/R) commonly to a limb, and it represents a new paradigm in neuroprotection with multiple mechanisms of action in ischemic stroke (IS) patients during acute phase. Some clinical trials just finished, and a few others are still ongoing; gather the current knowledge and pull it down to influence the present and future studies was the goal of this paper. METHODS A systematic review of published research papers and/or registered clinical trials since 2000 was performed. RESULTS Nineteen studies were identified and only four studies were completed. All of them have demonstrated that RIPerC is safe, feasible and well tolerated in IS patients. However, a high heterogeneity of clinical trial characteristics was observed: five (26.3%) randomized clinical trials (RCTs) included only thrombolytic-treated patients, three (15.8%) RCTs only thrombectomy-treated patients, and five (26.3%) RCTs required radiological confirmation of IS. Temporal inclusion criteria vary from 4 h to 48 h. Most of the clinical trials used 4 cycles of RIPerC in the upper non-affected limb. Interestingly, only three (16.7%) RCTs applied RIPerC during the transportation in the ambulance. Neuroimaging outputs were the main endpoints when endovascular therapy was applied; functional outcome is also the main endpoint in large-medium size studies. CONCLUSIONS This review summarizes the completed and ongoing clinical trials on RIPerC in IS patients, where RIPerC has been used alone or in combination with recanalization therapies. Ongoing clinical trials will provide new information on the best RIPerC intervention strategy and potentially improve the functional outcome of IS patients; definition of new RIPerC strategies would ideally aim at enhancing tissue preservation, promoting neurological recovery, and stratify patients to improve treatment feasibility.
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Affiliation(s)
- Francisco Purroy
- Stroke Unit, Department of Neurology, Universitat de Lleida, Hospital Universitari Arnau de Vilanova, Avda Rovira Roure 80, 25198, Lleida, Spain. .,Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). UdL, Lleida, Spain.
| | - Cristina García
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). UdL, Lleida, Spain
| | - Gerard Mauri
- Stroke Unit, Department of Neurology, Universitat de Lleida, Hospital Universitari Arnau de Vilanova, Avda Rovira Roure 80, 25198, Lleida, Spain.,Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). UdL, Lleida, Spain
| | - Cristina Pereira
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). UdL, Lleida, Spain
| | - Coral Torres
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). UdL, Lleida, Spain
| | - Daniel Vazquez-Justes
- Stroke Unit, Department of Neurology, Universitat de Lleida, Hospital Universitari Arnau de Vilanova, Avda Rovira Roure 80, 25198, Lleida, Spain.,Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). UdL, Lleida, Spain
| | - Mikel Vicente-Pascual
- Stroke Unit, Department of Neurology, Universitat de Lleida, Hospital Universitari Arnau de Vilanova, Avda Rovira Roure 80, 25198, Lleida, Spain.,Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). UdL, Lleida, Spain
| | - Ana Vena
- Stroke Unit, Department of Neurology, Universitat de Lleida, Hospital Universitari Arnau de Vilanova, Avda Rovira Roure 80, 25198, Lleida, Spain.,Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). UdL, Lleida, Spain
| | - Gloria Arque
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida). UdL, Lleida, Spain.
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17
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Damasceno AVBS, de Barros CAV, Percario S, Ribeiro RFG, Monteiro AM, Gouveia EHH, Henriques HYB. Remote ischemic conditioning protects against testicular ischemia∕reperfusion injury in rats. Acta Cir Bras 2020; 35:e202000203. [PMID: 32348402 PMCID: PMC7184938 DOI: 10.1590/s0102-865020200020000003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/05/2019] [Accepted: 01/03/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the effect of remote ischemic conditioning associated to N-acetylcysteine (NAC) on testicular ischemia∕reperfusion (I∕R) injury in rats. Methods Twenty-five adult male Wistar rats were randomly distributed into five experimental groups (n=5), as follows: Sham, I∕R, Perconditioning (PER), NAC and PER+NAC. Two-hour ischemia was induced by rotating the left testis 720° to clockwise direction, followed by 4 hours of reperfusion. Perconditioning was performed by three I/R cycles of 10 min each on the left limb, 30 min before reperfusion. N-acetylcysteine (150 mg∕kg) was administered 30 min before reperfusion. Results Statistical differences were observed in MDA levels between I/R group with all groups (p<0.01), in addition there was statistical difference between PER and Sham, and PER+ NAC groups (p<0.05) in plasma. Conclusions The protective effect of perconditioning isolated in the reduction of lipid peroxidation related to oxidative stress was demonstrated. However, when Perconditioning was associated with NAC, there was no protective effect against testicular injury of ischemia and reperfusion.
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Affiliation(s)
- Ananda Vitória Barros Suzuki Damasceno
- Graduate student, School of Medicine, Universidade do Estado do Pará (UEPA), Belem-PA, Brazil. Care of animals, technical procedures, interpretation of data, manuscript preparation
| | - Charles Alberto Villacorta de Barros
- PhD, Full Professor, Head, Division Surgical Abilities, UEPA, Belem-PA, Brazil. Conception, design, and scientific content of study, critical revision
| | - Sandro Percario
- PhD, DSc, Associate Professor, Oxidative Stress Research Lab Coordinator, UEPA, Belem-PA, Brazil. Conception and design of the study, statistical analysis, English version, critical revision
| | - Rubens Fernando Gonçalves Ribeiro
- Master, Postgraduate Program in Surgery and Experimental Research, UEPA, Belem-PA, Brazil. Statistical analysis, manuscript preparation, English version
| | - Andrew Moraes Monteiro
- Graduate student, UEPA, Belem-PA, Brazil. Care of the animals, technical procedures, interpretation of data, manuscript preparation
| | - Eduardo Henrique Herbster Gouveia
- MD, Graduated from Centro Universitário do Estado do Pará. Brazil. Care of animals, technical procedures, interpretation of data, manuscript preparation
| | - Higor Yuri Bezerra Henriques
- MD, Graduated from Centro Universitário do Estado do Pará. Brazil. Care of animals, technical procedures, interpretation of data, manuscript preparation
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Blanco S, Peralta S, Morales ME, Martínez-Lara E, Pedrajas JR, Castán H, Peinado MÁ, Ruiz MA. Hyaluronate Nanoparticles as a Delivery System to Carry Neuroglobin to the Brain after Stroke. Pharmaceutics 2020; 12:pharmaceutics12010040. [PMID: 31947806 PMCID: PMC7023086 DOI: 10.3390/pharmaceutics12010040] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/10/2019] [Accepted: 01/01/2020] [Indexed: 01/27/2023] Open
Abstract
Therapies against stroke can restore the blood supply but cannot prevent the ischemic damage nor stimulate the recovery of the infarcted zone. The neuroglobin protein plays an important role in the neuro-regeneration process after stroke; however, the method for its effective systemic application has not been identified yet, as neuroglobin is unable to pass through the blood-brain barrier. Previously, we developed different types of sodium hyaluronate nanoparticles, which successfully cross the blood-brain barrier after stroke. In this work, these nanoparticles have been used to carry neuroglobin through the bloodstream to the nerve cells in rats submitted to stroke. We have biosynthesized rat-recombinant neuroglobin and determined the formulation of sodium hyaluronate nanoparticles loaded with neuroglobin, as well as its size and ζ-potential, encapsulation efficiently, in vitro release, and its kinetic of liberation. The results show that the formulation achieved is highly compatible with pharmaceutical use and may act as a delivery system to transport neuroglobin within the blood. We have found that this formulation injected intravenously immediately after stroke reached the damaged cerebral parenchyma at early stages (2 h). Neuroglobin colocalizes with its nanocarriers inside the nerve cells and remains after 24 h of reperfusion. In conclusion, the systemic administration of neuroglobin linked to nanoparticles is a potential neuroprotective drug-delivery strategy after stroke episodes.
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Affiliation(s)
- Santos Blanco
- Department of Experimental Biology, University of Jaén, Building B3, Campus de Las Lagunillas s/n, 23071 Jaén, Spain; (S.B.); (E.M.-L.); (J.R.P.)
| | - Sebastián Peralta
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Granada, Campus de Cartuja s/n, 18071 Granada, Spain; (S.P.); (M.E.M.); (H.C.)
| | - María Encarnación Morales
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Granada, Campus de Cartuja s/n, 18071 Granada, Spain; (S.P.); (M.E.M.); (H.C.)
| | - Esther Martínez-Lara
- Department of Experimental Biology, University of Jaén, Building B3, Campus de Las Lagunillas s/n, 23071 Jaén, Spain; (S.B.); (E.M.-L.); (J.R.P.)
| | - José Rafael Pedrajas
- Department of Experimental Biology, University of Jaén, Building B3, Campus de Las Lagunillas s/n, 23071 Jaén, Spain; (S.B.); (E.M.-L.); (J.R.P.)
| | - Herminia Castán
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Granada, Campus de Cartuja s/n, 18071 Granada, Spain; (S.P.); (M.E.M.); (H.C.)
| | - María Ángeles Peinado
- Department of Experimental Biology, University of Jaén, Building B3, Campus de Las Lagunillas s/n, 23071 Jaén, Spain; (S.B.); (E.M.-L.); (J.R.P.)
- Correspondence: (M.Á.P.); (M.A.R.)
| | - María Adolfina Ruiz
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Granada, Campus de Cartuja s/n, 18071 Granada, Spain; (S.P.); (M.E.M.); (H.C.)
- Correspondence: (M.Á.P.); (M.A.R.)
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19
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Wang Z, Li X, Li N, Huang L, Liu J, Yang B, Shi J, Fei Y, Ji X, Gao K, Ren M. Safety and Tolerability of Both Arm Ischemic Conditioning in Patients With Major Depression: A Proof of Concept Study. Front Psychiatry 2020; 11:570. [PMID: 32625124 PMCID: PMC7316084 DOI: 10.3389/fpsyt.2020.00570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/03/2020] [Indexed: 12/23/2022] Open
Abstract
PURPOSE A substantial proportion of patients with major depressive disorder (MDD) does not respond or cannot tolerate to currently available treatments. This study was to assess the safety and tolerability of Remote Limb Ischemic Preconditioning (RLIPC) as an adjunctive therapy in patients with MDD. PATIENTS AND METHODS Enrolled patients underwent RLIPC, five cycles of simultaneous bilateral arm ischemia, 5 min and followed by reperfusion of each cycle, and once daily for eight consecutive weeks. Depression and anxiety severity, and quality of life were assessed every 2 weeks. Descriptive analysis was used for safety and tolerability data. RESULTS Thirty-seven participants completed at least one RLIPC. Twenty-four of them (64.9%) completed the study. Twelve patients prematurely discontinued the study due to poor adherence, and one due to a mild side effect. The changes in HRSD-17, GAD-7 and QOL-6 total scores from baseline to the endpoint were significant from the end of second week treatment onwards. The responder and remission rates were 59.46% (22/37) and 54.05% (20/37) at the endpoint, respectively. CONCLUSION RLIPC was safe and well tolerated, and may be effective in reducing depressive symptoms in patients with MDD. Large studies are warranted to test its efficacy and safety as monotherapy or adjunctive therapy in the treatment of MDD.
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Affiliation(s)
- Zuowei Wang
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China.,School of Medicine, Shanghai University, Shanghai, China.,Department of Psychology, Naval Medical University, Shanghai, China
| | - Xujuan Li
- Department of Psychiatry, Shulan (Hangzhou) Hospital, Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Ningning Li
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China
| | - Leping Huang
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China
| | - Jiawen Liu
- Department of Psychiatry, Shulan (Hangzhou) Hospital, Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Bixiu Yang
- Department of Psychology, Wuxi Mental Health Center, Wuxi, China
| | - Jingquan Shi
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China
| | - Yue Fei
- Division of Mood Disorders, Hongkou District Mental Health Center, Shanghai, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Keming Gao
- Mood and Anxiety Clinic in the Mood Disorders Program of the Department of Psychiatry, University Hospital Cleveland Medical Center, Cleveland, OH, United States.,Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Ming Ren
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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20
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Mohammad Seyedsaadat S, Kallmes DF, Brinjikji W. Remote ischemic conditioning approach for the treatment of ischemic stroke. Neural Regen Res 2020; 15:1033-1034. [PMID: 31823878 PMCID: PMC7034284 DOI: 10.4103/1673-5374.270303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, USA
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21
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England TJ, Hedstrom A, O'Sullivan SE, Woodhouse L, Jackson B, Sprigg N, Bath PM. Remote Ischemic Conditioning After Stroke Trial 2: A Phase IIb Randomized Controlled Trial in Hyperacute Stroke. J Am Heart Assoc 2019; 8:e013572. [PMID: 31747864 PMCID: PMC6912955 DOI: 10.1161/jaha.119.013572] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/23/2019] [Indexed: 11/16/2022]
Abstract
Background Repeated episodes of limb ischemia and reperfusion (remote ischemic conditioning [RIC]) may protect the brain from ischemic reperfusion injury. Methods and Results We performed a phase IIb blinded dose-escalation sham-controlled trial in patients with hyperacute stroke, randomized 1:1 to receive RIC (four 5-minute cycles) or sham to the nonparetic upper limb, in 3 blocks of increasing dose, starting within 6 hours of ictus. The primary outcome was trial feasibility (recruitment, attrition). Secondary outcomes included adherence, tolerability, safety (serious adverse events), plasma biomarkers at days 1 and 4 (S100-ß protein, matrix metalloproteinase-9, and neuron-specific enolase), and functional outcome. Sixty participants were recruited from 2 centers (3 per month) with no loss to follow-up: time to randomization 4 hours 5 minutes (SD 72 minutes), age 72 years (12), men 60%, blood pressure 154/80 mm Hg (25/12), National Institutes of Health Stroke Scale 8.4 (6.9), and 55% thrombolyzed. RIC was well tolerated with adherence not differing between RIC and sham, falling in both groups on day 3 (P=0.001, repeated measures ANOVA) because of discharge or transfer. S100ß increased in the sham group (mean rise 111 pg/mL [302], P=0.041, repeated measures ANCOVA) but not the RIC group. There were no differences in matrix metalloproteinase-9, neuron-specific enolase, number with serious adverse events (RIC 10 versus sham 10, P=0.81), deaths (2 versus 4, P=0.36), or modified Rankin Scale score (2 [interquartile range 1-4], 2 [interquartile range, 1-3]; P=0.85). Conclusions RIC in hyperacute stroke is feasible when given twice daily for 2 days and appears safe in a small population with hyperacute stroke. A larger phase III trial is warranted. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02779712.
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Affiliation(s)
- Timothy J. England
- Vascular MedicineDivision of Medical Sciences and GEMSchool of MedicineUniversity of NottinghamDerbyUnited Kingdom
- StrokeRoyal Derby HospitalUniversity Hospitals of Derby and BurtonNHS Foundation TrustDerbyUnited Kingdom
| | - Amanda Hedstrom
- Vascular MedicineDivision of Medical Sciences and GEMSchool of MedicineUniversity of NottinghamDerbyUnited Kingdom
| | - Saoirse E. O'Sullivan
- Vascular MedicineDivision of Medical Sciences and GEMSchool of MedicineUniversity of NottinghamDerbyUnited Kingdom
| | - Lisa Woodhouse
- Stroke Trials UnitDivision of Clinical NeuroscienceCity Hospital CampusUniversity of NottinghamNottinghamUnited Kingdom
| | - Ben Jackson
- Stroke Trials UnitDivision of Clinical NeuroscienceCity Hospital CampusUniversity of NottinghamNottinghamUnited Kingdom
| | - Nikola Sprigg
- Stroke Trials UnitDivision of Clinical NeuroscienceCity Hospital CampusUniversity of NottinghamNottinghamUnited Kingdom
- StrokeNottingham University Hospitals NHS TrustCity Hospital CampusNottinghamUnited Kingdom
| | - Philip M. Bath
- Stroke Trials UnitDivision of Clinical NeuroscienceCity Hospital CampusUniversity of NottinghamNottinghamUnited Kingdom
- StrokeNottingham University Hospitals NHS TrustCity Hospital CampusNottinghamUnited Kingdom
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22
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Zhou D, Ding J, Ya J, Pan L, Wang Y, Ji X, Meng R. Remote ischemic conditioning: a promising therapeutic intervention for multi-organ protection. Aging (Albany NY) 2019; 10:1825-1855. [PMID: 30115811 PMCID: PMC6128414 DOI: 10.18632/aging.101527] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 08/10/2018] [Indexed: 12/21/2022]
Abstract
Despite decades of formidable exploration, multi-organ ischemia-reperfusion injury (IRI) encountered, particularly amongst elderly patients with clinical scenarios, such as age-related arteriosclerotic vascular disease, heart surgery and organ transplantation, is still an unsettled conundrum that besets clinicians. Remote ischemic conditioning (RIC), delivered via transient, repetitive noninvasive IR interventions to distant organs or tissues, is regarded as an innovative approach against IRI. Based on the available evidence, RIC holds the potential of affording protection to multiple organs or tissues, which include not only the heart and brain, but also others that are likely susceptible to IRI, such as the kidney, lung, liver and skin. Neuronal and humoral signaling pathways appear to play requisite roles in the mechanisms of RIC-related beneficial effects, and these pathways also display inseparable interactions with each other. So far, several hurdles lying ahead of clinical translation that remain to be settled, such as establishment of biomarkers, modification of RIC regimen, and deep understanding of underlying minutiae through which RIC exerts its powerful function. As this approach has garnered an increasing interest, herein, we aim to encapsulate an overview of the basic concept and postulated protective mechanisms of RIC, highlight the main findings from proof-of-concept clinical studies in various clinical scenarios, and also to discuss potential obstacles that remain to be conquered. More well designed and comprehensive experimental work or clinical trials are warranted in future research to confirm whether RIC could be utilized as a non-invasive, inexpensive and efficient adjunct therapeutic intervention method for multi-organ protection.
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Affiliation(s)
- Da Zhou
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Jiayue Ding
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Jingyuan Ya
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Liqun Pan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
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23
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Yang Q, Huang Q, Hu Z, Tang X. Potential Neuroprotective Treatment of Stroke: Targeting Excitotoxicity, Oxidative Stress, and Inflammation. Front Neurosci 2019; 13:1036. [PMID: 31611768 PMCID: PMC6777147 DOI: 10.3389/fnins.2019.01036] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 09/12/2019] [Indexed: 01/08/2023] Open
Abstract
Stroke is a major cause of death and adult disability. However, therapeutic options remain limited. Numerous pathways underlie acute responses of brain tissue to stroke. Early events following ischemic damage include reactive oxygen species (ROS)-mediated oxidative stress and glutamate-induced excitotoxicity, both of which contribute to rapid cell death within the infarct core. A subsequent cascade of inflammatory events escalates damage progression. This review explores potential neuroprotective strategies for targeting key steps in the cascade of ischemia–reperfusion (I/R) injury. NADPH oxidase (NOX) inhibitors and several drugs currently approved by the U.S. Food and Drug Administration including glucose-lowering agents, antibiotics, and immunomodulators, have shown promise in the treatment of stroke in both animal experiments and clinical trials. Ischemic conditioning, a phenomenon by which one or more cycles of a short period of sublethal ischemia to an organ or tissue protects against subsequent ischemic events in another organ, may be another potential neuroprotective strategy for the treatment of stroke by targeting key steps in the I/R injury cascade.
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Affiliation(s)
- Qianwen Yang
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Qianyi Huang
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhiping Hu
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiangqi Tang
- Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, China
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24
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Landman T, Schoon Y, Warlé M, De Leeuw FE, Thijssen D. The effect of repeated remote ischemic postconditioning on infarct size in patients with an ischemic stroke (REPOST): study protocol for a randomized clinical trial. Trials 2019; 20:167. [PMID: 30876432 PMCID: PMC6419836 DOI: 10.1186/s13063-019-3264-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 02/27/2019] [Indexed: 01/28/2023] Open
Abstract
Background Remote ischemic postconditioning (rIPostC) refers to the observation that repeated, short periods of ischemia protect remote areas against tissue damage during and after prolonged ischemia. Based on previous observations of a potential neuroprotective effect of rIPostC, the aim of this study is to evaluate whether repeated rIPostC after an ischemic stroke can reduce infarct size, which could be translated to an improvement in clinical outcomes. Methods/design We will enroll 200 ischemic stroke patients to daily rIPostC or sham conditioning during hospitalization into a randomized single-blind placebo-controlled trial. The intervention consists of twice daily exposure to four cycles of 5-min cuff inflation around the upper arm to > 20 mmHg above systolic blood pressure (i.e., rIPostC) or 50 mmHg (i.e., control), followed by 5 minutes of deflation. The primary outcome is infarct size, measured using an MRI diffusion-weighted image at the end of hospitalization. Secondary outcomes include the Modified Rankin Scale, National Institutes of Health Stroke Scale, quality of life, and cardiovascular and cerebrovascular morbidity and mortality. To explore possible underlying mechanisms of rIPostC, venous blood will be sampled to assess biomarkers of inflammation and vascular health. Discussion Previous studies in animals and humans, using a single bout of remote ischemic conditioning, report a potential effect of rIPostC in attenuating neural damage. Although repeated rIPostC has been investigated for cardiovascular disease patients and preclinical stroke models, no previous study has explored the potential physiological and clinical effects of repeatedly applying rIPostC during the hospitalization phase after a stroke. Trial registration Netherlands Trial Register, NTR6880. Registered on 8 December 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3264-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thijs Landman
- Department of Physiology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands.
| | - Yvonne Schoon
- Department of Geriatric Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
| | - Michiel Warlé
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
| | - Frank-Erik De Leeuw
- Centre for Cognitive Neuroscience, Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
| | - Dick Thijssen
- Department of Physiology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, Gelderland, Netherlands
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25
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Che R, Zhao W, Ma Q, Jiang F, Wu L, Yu Z, Zhang Q, Dong K, Song H, Huang X, Ji X. rt-PA with remote ischemic postconditioning for acute ischemic stroke. Ann Clin Transl Neurol 2019; 6:364-372. [PMID: 30847368 PMCID: PMC6389851 DOI: 10.1002/acn3.713] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/18/2018] [Accepted: 11/29/2018] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the feasibility and safety of remote ischemic postconditioning (RIPC) in acute ischemic stroke patients after intravenous recombinant tissue plasminogen activator (rt‐PA) thrombolysis (IVT). Methods We performed a pilot randomized trial involving acute ischemic stroke patients with IVT. The patients were randomized 1:1 to receive RIPC or standard medical therapy. In the RIPC group, the participants underwent instant RIPC within 2 h of IVT, followed by repeated RIPC therapy for 7 days. The feasibility end point was the completion of RIPC and time from the first RIPC to finishing IVT in the RIPC group. The safety end point included tissue and neurovascular injury resulting from RIPC, changes in vital signs, level of plasma myoglobin, any hemorrhagic transformation, and other adverse events. Results Thirty patients (15 RIPC and 15 Control) were recruited after IVT. The mean age was 65.7 ± 10.2 years, with a National Institutes of Health Stroke Scale (NIHSS) score of 6.5 (4.0–10.0). The completion rate for RIPC was 97.0%. The mean time from first RIPC to completing IVT was 66.0 (25.0–75.0) min in the RIPC group. One case of hemorrhagic transformation was observed in the RIPC group. No significant difference was found in the level of myoglobin between the two groups (P > 0.05). Interpretation RIPC is effective and safe for AIS patients after intravenous rt‐PA thrombolysis.
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Affiliation(s)
- Ruiwen Che
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Wenbo Zhao
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Qingfeng Ma
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Fang Jiang
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Longfei Wu
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Zhipeng Yu
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Qian Zhang
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Kai Dong
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Haiqing Song
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Xiaoqin Huang
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China.,Department of Neurosurgery Xuanwu Hospital Capital Medical University Beijing China
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26
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Doeppner TR, Zechmeister B, Kaltwasser B, Jin F, Zheng X, Majid A, Venkataramani V, Bähr M, Hermann DM. Very Delayed Remote Ischemic Post-conditioning Induces Sustained Neurological Recovery by Mechanisms Involving Enhanced Angioneurogenesis and Peripheral Immunosuppression Reversal. Front Cell Neurosci 2018; 12:383. [PMID: 30420796 PMCID: PMC6216109 DOI: 10.3389/fncel.2018.00383] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/08/2018] [Indexed: 01/06/2023] Open
Abstract
Ischemic conditioning is defined as a transient and subcritical period of ischemia integrated in an experimental paradigm that involves a stimulus of injurious ischemia, activating endogenous tissue repair mechanisms that lead to cellular protection under pathological conditions like stroke. Whereas ischemic pre-conditioning is irrelevant for stroke treatment, ischemic post-conditioning, and especially non-invasive remote ischemic post-conditioning (rPostC) is an innovative and potential strategy for stroke treatment. Although rPostC has been shown to induce neuroprotection in stroke models before, resulting in some clinical trials on the way, fundamental questions with regard to its therapeutic time frame and its underlying mechanisms remain elusive. Hence, we herein used a model of non-invasive rPostC of hind limbs after cerebral ischemia in male C57BL6 mice, studying the optimal timing for the application of rPostC and its underlying mechanisms for up to 3 months. Mice undergoing rPostC underwent three different paradigms, starting with the first cycle of rPostC 12 h, 24 h, or 5 days after stroke induction, which is a very delayed time point of rPostC that has not been studied elsewhere. rPostC as applied within 24 h post-stroke induces reduction of infarct volume on day three. On the contrary, very delayed rPostC does not yield reduction of infarct volume on day seven when first applied on day five, albeit long-term brain injury is significantly reduced. Likewise, very delayed rPostC yields sustained neurological recovery, whereas early rPostC (i.e., <24 h) results in transient neuroprotection only. The latter is mediated via heat shock protein 70 that is a well-known signaling protein involved in the pathophysiological cellular cascade of cerebral ischemia, leading to decreased proteasomal activity and decreased post-stroke inflammation. Very delayed rPostC on day five, however, induces a pleiotropic effect, among which a stimulation of angioneurogenesis, a modulation of the ischemic extracellular milieu, and a reversal of the stroke-induced immunosuppression occur. As such, very delayed rPostC appears to be an attractive tool for future adjuvant stroke treatment that deserves further preclinical attention before large clinical trials are in order, which so far have predominantly focused on early rPostC only.
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Affiliation(s)
- Thorsten R Doeppner
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Bozena Zechmeister
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Britta Kaltwasser
- Department of Neurology, University Duisburg-Essen Medical School, Essen, Germany
| | - Fengyan Jin
- Cancer Center, The First Hospital of Jilin University, Changchun, China
| | - Xuan Zheng
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Arshad Majid
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - Vivek Venkataramani
- Department of Hematology & Oncology, University Medical Center Göttingen, Göttingen, Germany.,Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Mathias Bähr
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Dirk M Hermann
- Department of Neurology, University Duisburg-Essen Medical School, Essen, Germany
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27
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Zhao W, Zhang J, Sadowsky MG, Meng R, Ding Y, Ji X. Remote ischaemic conditioning for preventing and treating ischaemic stroke. Cochrane Database Syst Rev 2018; 7:CD012503. [PMID: 29974450 PMCID: PMC6513257 DOI: 10.1002/14651858.cd012503.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Remote ischaemic conditioning (RIC) has been developed as a neuroprotective strategy to prevent and treat ischaemic stroke. It usually involves restricting blood flow to limbs and then releasing the ischaemic blood to promote a neuroprotective effect. Preclinical studies have suggested that RIC may have beneficial effects in ischaemic stroke patients and those at risk of ischaemic stroke. However, existing evidence is insufficient to demonstrate the efficacy and safety of RIC in preventing and treating ischaemic stroke. OBJECTIVES To assess the benefits and harms of RIC for preventing ischaemic stroke and for treating people with ischaemic stroke and those at risk for ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (16 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (January 2018), MEDLINE Ovid (1946 to January 2018), Embase Ovid (1974 to January 2018), Web of Science Core Collection (1950 to January 2018) and three Chinese databases (January 2018). We also searched four ongoing trials registers, reference lists, and conference proceedings. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing RIC with sham RIC or medical management in people with ischaemic stroke or at risk of ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed trial quality and risk of bias, and extracted data. We used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included seven trials, involving 735 participants, in this review. We analysed the effects of RIC on preventing and treating ischaemic stroke respectively.We evaluated risk of bias and judged it to be low for generation of allocation sequence in six studies and unclear in one study; unclear for allocation concealment in four studies and low in three studies; high for incomplete outcome data (attrition bias) in five studies and low in two studies; high for blinding in three studies and low in four studies; low for selective reporting; and high for other sources of bias in six studies and low in one study.We included three trials (involving 371 participants) in the analysis of the effects of RIC on ischaemic stroke prevention. In people with symptomatic intracerebral artery stenosis, recurrent stroke was significantly reduced by RIC (risk ratio (RR) 0.32, 95% confidence interval (CI) 0.12 to 0.83; 2 trials, 182 participants, low-quality evidence). In people with carotid stenosis undergoing carotid stenting, there was no significant difference in the incidence of ischaemic stroke between participants treated with RIC and non-RIC (RR 0.22, 95% CI 0.01 to 4.03; 1 trial, 189 participants, low-quality evidence); however the stroke severity (assessed by infarct volume) was significantly lower in participants treated with RIC (mean difference (MD) -0.17 mL, 95% CI -0.23 to -0.11; 1 trial, 189 participants, low-quality evidence). Adverse events associated with RIC were significantly higher in participants treated with RIC (RR 10.91; 95% CI 2.01 to 59.28; 3 trials, 371 participants, low-quality evidence), but no severe adverse event was attributable to RIC treatment. No participants experienced death or cardiovascular events during the period of the studies; and no trial reported haemorrhagic stroke or improvement in neurological, phycological or cognitive impairment.We included four trials (involving 364 participants) in the analysis of the effects of RIC on ischaemic stroke treatment. In acute ischaemic stroke, for people receiving intravenous thrombolysis, the rate of death or dependency was significantly increased by RIC treatment compared with non-RIC treatment (RR 2.34; 95% 1.19 to 4.61; 1 trial, 285 participants, low-quality evidence). In people with acute ischaemic stroke, there was no significant difference between RIC and non-RIC for reducing stroke severity as assessed by the National Institutes of Health Stroke Scale score and the final infarct volume (standardised mean difference (SMD) -0.24 mL, 95% CI -1.02 to 0.54; 2 trials, 175 participants, very low quality evidence). There was no significant difference between RIC and non-RIC for improving the psychological impairment (SMD -0.37 points, 95% CI -1.15 to 0.41; 1 trial, 26 participants, very low quality evidence) and the cognitive impairment (SMD -0.26 points; 95% CI -0.72 to 0.21; 3 trials, 79 participants, low-quality evidence) in people with acute ischaemic stroke and cerebral small vessel disease. No trial reported ischaemic stroke, recurrent ischaemic stroke, improvement in neurological impairment, hemorrhagic stroke, cardiovascular events, and RIC associated adverse events. AUTHORS' CONCLUSIONS We found low-quality evidence that RIC may reduce the risk of recurrent stroke in participants with intracerebral artery stenosis and reduce stroke severity in participants undergoing carotid stenting, but it may increase death or dependence in participants with acute ischaemic stroke who are undergoing intravenous thrombolysis. However, there is considerable uncertainty about these conclusions because of the small number of studies and low quality of the evidence.
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Affiliation(s)
- Wenbo Zhao
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyBeijingChina100053
| | - Jing Zhang
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyBeijingChina100053
| | - Mordechai G Sadowsky
- Wayne State University School of MedicineDepartment of Neurological SurgeryDetroit, MichiganUSA
| | - Ran Meng
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyBeijingChina100053
| | - Yuchuan Ding
- Wayne State University School of MedicineDepartment of Neurological SurgeryDetroit, MichiganUSA
| | - Xunming Ji
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurosurgeryBeijingChina100053
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28
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Zhao W, Che R, Li S, Ren C, Li C, Wu C, Lu H, Chen J, Duan J, Meng R, Ji X. Remote ischemic conditioning for acute stroke patients treated with thrombectomy. Ann Clin Transl Neurol 2018; 5:850-856. [PMID: 30009202 PMCID: PMC6043766 DOI: 10.1002/acn3.588] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/27/2018] [Accepted: 05/08/2018] [Indexed: 01/01/2023] Open
Abstract
Objective Remote ischemic conditioning (RIC) has been demonstrated to be safe and feasible for patients with acute ischemic stroke (AIS), as well as for those receiving intravenous thrombolysis. We assessed the safety and feasibility of RIC for AIS patients undergoing endovascular treatment (ET). Methods We conducted a pilot study with patients with AIS who were suspected of having an emergent large‐vessel occlusion in the anterior circulation and who were scheduled for ET within 6 hours of ictus. Four cycles of RIC were performed before recanalization, immediately following recanalization, and once daily for the subsequent 7 days. The primary outcome was any serious RIC‐related adverse events. Results Twenty subjects, aged 66.1 ± 12.1 years, were recruited. No subject experienced serious RIC‐related adverse events. The intracranial pressure, cranial perfusion pressure, mean arterial pressure, heart rate, middle cerebral artery peak systolic flow velocity, and pulsatility index did not change significantly before, during, or after the limb ischemia (P > 0.1 for all). Of 80 cycles, 71 (89%) were completed before recanalization and 80 (100%) were completed immediately after recanalization; 444 of 560 cycles (78%) were completed within 7 days posttreatment. No patients had to stop RIC because it affected routine clinical managements. Six subjects (30%) experienced intracerebral hemorrhage, which was symptomatic in one case (5%). At the 3‐month follow‐up, 11 subjects (55%) had achieved functional independence, and two subjects (10%) died. Interpretation RIC appears to be safe and feasible for patients with AIS undergoing ET. Investigations are urgently needed to determine the efficacy of RIC in this patient population.
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Affiliation(s)
- Wenbo Zhao
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Ruiwen Che
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Sijie Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Chuanhui Li
- Department of Neurosurgery Xuanwu Hospital Capital Medical University Beijing China
| | - Chuanjie Wu
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Hui Lu
- Department of Neurology Brain Hospital of Cangzhou Central Hospital Hebei China
| | - Jian Chen
- Department of Neurosurgery Xuanwu Hospital Capital Medical University Beijing China
| | - Jiangang Duan
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Ran Meng
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China.,Department of Neurosurgery Xuanwu Hospital Capital Medical University Beijing China
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Chen G, Thakkar M, Robinson C, Doré S. Limb Remote Ischemic Conditioning: Mechanisms, Anesthetics, and the Potential for Expanding Therapeutic Options. Front Neurol 2018; 9:40. [PMID: 29467715 PMCID: PMC5808199 DOI: 10.3389/fneur.2018.00040] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/17/2018] [Indexed: 12/23/2022] Open
Abstract
Novel and innovative approaches are essential in developing new treatments and improving clinical outcomes in patients with ischemic stroke. Remote ischemic conditioning (RIC) is a series of mechanical interruptions in blood flow of a distal organ, following end organ reperfusion, shown to significantly reduce infarct size through inhibition of oxidation and inflammation. Ischemia/reperfusion (I/R) is what ultimately leads to the irreversible brain damage and clinical picture seen in stroke patients. There have been several reports and reviews about the potential of RIC in acute ischemic stroke; however, the focus here is a comprehensive look at the differences in the three types of RIC (remote pre-, per-, and postconditioning). There are some limited uses of preconditioning in acute ischemic stroke due to the unpredictability of the ischemic event; however, it does provide the identification of biomarkers for clinical studies. Remote limb per- and postconditioning offer a more promising treatment during patient care as they can be harnessed during or after the initial ischemic insult. Though further research is needed, it is imperative to discuss the importance of preclinical data in understanding the methods and mechanisms involved in RIC. This understanding will facilitate translation to a clinically feasible paradigm for use in the hospital setting.
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Affiliation(s)
- Gangling Chen
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, United States.,Department of Pharmacology of Chinese Materia Medica, China Pharmaceutical University, Nanjing, China
| | - Mrugesh Thakkar
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, United States
| | - Christopher Robinson
- McKnight Brain Institute, University of Florida, Gainesville, FL, United States.,Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Sylvain Doré
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease, University of Florida, Gainesville, FL, United States.,McKnight Brain Institute, University of Florida, Gainesville, FL, United States.,Department of Neurology, University of Florida, Gainesville, FL, United States.,Department of Psychiatry, University of Florida, Gainesville, FL, United States.,Department of Pharmaceutics, University of Florida, Gainesville, FL, United States.,Department of Psychology, University of Florida, Gainesville, FL, United States.,Department of Neuroscience, University of Florida, Gainesville, FL, United States
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30
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Ren C, Li S, Liu K, Rajah GB, Zhang A, Han R, Liu Y, Huang Q, Li H, Ding Y, Ji X. Enhanced oxidative stress response and neuroprotection of combined limb remote ischemic conditioning and atorvastatin after transient ischemic stroke in rats. Brain Circ 2017; 3:204-212. [PMID: 30276326 PMCID: PMC6057710 DOI: 10.4103/bc.bc_29_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 12/04/2017] [Accepted: 12/05/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND: Limb remote ischemic conditioning (LRIC) and atorvastatin (AtS) both provide neuroprotection in stroke. We evaluated the enhanced neuroprotective effect of combining these two treatments in preventing ischemia/reperfusion (I/R)-induced cerebral injury in a rat model and investigated the corresponding molecular mechanisms. MATERIALS AND METHODS: Transient cerebral ischemia was induced in Sprague–Dawley male rats by middle cerebral artery occlusion (MCAO) for 90 min followed by reperfusion (I/R). Rats were divided into 5 groups, sham, I/R, I/R + AtS, I/R + LRIC and I/R + AtS + LRIC. Pretreatment with LRIC and/or AtS for 14 days before MCAO surgery. Infarct volume, neurological score, Western blot, immuno-histochemical analyses were performed. RESULTS: The combination of LRIC plus AtS pretreatment decreased infarct volume and inhibited neuronal apoptosis. Combination treatment achieved stronger neuroprotection than monotherapy with LRIC or AtS. These therapies reduced reactive oxygen species production in the peri-ischemia region, associated with significantly increased expression and activation of superoxide dismutase 1, hemeoxygenase 1 and nuclear factor erythroid 2-related factor 2. CONCLUSIONS: Both LRIC and AtS + LRIC treatments conferred neuroprotection in ischemic stroke by reducing brain oxidative stress. AtS plus LRIC is an attractive translational research option due to its ease of use, tolerability, economical, and tremendous neuroprotective potential in stroke.
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Affiliation(s)
- Changhong Ren
- Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorder, Beijing, China
| | - Sijie Li
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China
| | - Kaiyin Liu
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Gary B Rajah
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Anbo Zhang
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China
| | - Rongrong Han
- Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorder, Beijing, China
| | - Yuanyuan Liu
- Department of Endocrinology, Beijing, China, Huai'an First People's Hospital, Nanjing Medical University, Huai'an 223300, Jiangsu Province, China
| | - Qingjian Huang
- Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorder, Beijing, China
| | - Haiyan Li
- Institute of Hypoxia Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorder, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorder, Beijing, China
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31
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Adstamongkonkul D, Hess DC. Ischemic Conditioning and neonatal hypoxic ischemic encephalopathy: a literature review. CONDITIONING MEDICINE 2017; 1:9-16. [PMID: 30215057 PMCID: PMC6131706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Hypoxic Ischemic Encephalopathy (HIE) is the result of severe anoxic brain injury during the neonatal period and causes life-long morbidity and premature mortality. Currently, therapeutic hypothermia immediately after birth is the standard of care for clinically relevant HIE. However, therapeutic hypothermia alone does not provide complete neuroprotection and there is an urgent need for adjunctive therapies. Ischemic conditioning is an adaptive process of endogenous protection in which small doses of sub-lethal ischemia can provide a protection against a lethal ischemic event. Remote Ischemic Post-conditioning (RIPC), a form of ischemic conditioning, is highly translatable for HIE diagnosed immediately after birth as the conditioned ischemic stimulus is applied at the limb after the lethal ischemic episode. A number of studies in neonatal rats have demonstrated that RIPC is effective at reducing injury in focal cerebral ischemia models and improves neurological outcomes. In this review, we focus on the available data on HIE and its current treatment, models in HIE studies, ischemic conditioning/RIPC and its mechanism. We discuss in particular the effect of RIPC on neonatal brain with HIE. We postulate that combining RIPC with standard therapeutic hypothermia can be an attractive therapeutic approach for HIE.
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Affiliation(s)
- Dusit Adstamongkonkul
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA
| | - David C Hess
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA
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32
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Zhao W, Jiang F, Zhang Z, Zhang J, Ding Y, Ji X. Remote Ischemic Conditioning: A Novel Non-Invasive Approach to Prevent Post-Stroke Depression. Front Aging Neurosci 2017; 9:270. [PMID: 28848427 PMCID: PMC5550409 DOI: 10.3389/fnagi.2017.00270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/26/2017] [Indexed: 01/22/2023] Open
Abstract
Post-stroke depression (PSD) is a common neuropsychiatric complication of stroke. However, due to the high expense and side effects of pharmacotherapy and the difficult-to-achieve of psychotherapy, the prevention and treatment of PSD are still far from satisfaction. Inflammation hypothesis is now playing an essential role in the pathophysiological mechanism of PSD, and it may be a new preventive and therapeutic target. Remote ischemic conditioning (RIC) is a non-invasive and easy-to-use physical strategy, which has been used to protect brain (including ischemic and hemorrhagic stroke), heart and many other organs in clinical trials. The underlying mechanisms of RIC include anti-inflammation, anti-oxidative stress, immune system regulation and other potential pathways. Our hypothesis is that RIC is a novel approach to prevent PSD. The important implications of this hypothesis are that: (1) RIC could be widely used in clinical practice to prevent PSD if our hypothesis were verified; and (2) RIC would be thoroughly explored to test its effects on other neurobehavioral disorders (e.g., cognitive impairment).
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Affiliation(s)
- Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical UniversityBeijing, China
| | - Fang Jiang
- Department of Neurology, Xuanwu Hospital, Capital Medical UniversityBeijing, China
| | - Zhen Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical UniversityBeijing, China
| | - Jing Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical UniversityBeijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of MedicineDetroit, MI, United States
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical UniversityBeijing, China
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Baez-Jurado E, Vega GG, Aliev G, Tarasov VV, Esquinas P, Echeverria V, Barreto GE. Blockade of Neuroglobin Reduces Protection of Conditioned Medium from Human Mesenchymal Stem Cells in Human Astrocyte Model (T98G) Under a Scratch Assay. Mol Neurobiol 2017; 55:2285-2300. [PMID: 28332151 DOI: 10.1007/s12035-017-0481-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/03/2017] [Indexed: 12/25/2022]
Abstract
Previous studies have indicated that paracrine factors (conditioned medium) increase wound closure and reduce reactive oxygen species in a traumatic brain injury in vitro model. Although the beneficial effects of conditioned medium from human adipose tissue-derived mesenchymal stem cells (hMSCA-CM) have been previously suggested for various neurological diseases, their actions on astrocytic cells are not well understood. In this study, we have explored the effect of hMSCA-CM on human astrocyte model (T98G cells) subjected to scratch assay. Our results indicated that hMSCA-CM improved cell viability, reduced nuclear fragmentation, attenuated the production of reactive oxygen species, and preserved mitochondrial membrane potential and ultrastructural parameters. In addition, hMSCA-CM upregulated neuroglobin in T98G cells and the genetic silencing of this protein prevented the protective action of hMSCA-CM on damaged cells, suggesting that neuroglobin is mediating, at least in part, the protective effect of hMSCA-CM. Overall, this evidence suggests that the use of hMSCA-CM is a promising therapeutic strategy for the protection of astrocytic cells in central nervous system (CNS) pathologies.
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Affiliation(s)
- Eliana Baez-Jurado
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - Gina Guio Vega
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, DC, Colombia
| | - Gjumrakch Aliev
- Institute of Physiologically Active Compounds Russian Academy of Sciences, Chernogolovka, 142432, Russia
- GALLY International Biomedical Research Consulting LLC, San Antonio, TX, 78229, USA
- School of Health Science and Healthcare Administration, University of Atlanta, Johns Creek, GA, 30097, USA
| | - Vadim V Tarasov
- Institute of Pharmacy and Translational Medicine, Sechenov First Moscow State Medical University, 2-4 Bolshaya Pirogovskaya st., 119991, Moscow, Russia
| | - Paula Esquinas
- Facultad Medicina Veterinaria y Zootecnia, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Valentina Echeverria
- Facultad Ciencias de la Salud, Universidad San Sebastián, Lientur 1457, 4030000, Concepción, Chile
| | - George E Barreto
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, DC, Colombia.
- Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Santiago, Chile.
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34
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Zhao W, Zhang J, Sadowsky MG, Meng R, Ding Y, Ji X. Remote ischaemic conditioning for preventing and treating ischaemic stroke. Hippokratia 2017. [DOI: 10.1002/14651858.cd012503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Wenbo Zhao
- Xuanwu Hospital, Capital Medical University; Department of Neurology; Beijing China 100053
| | - Jing Zhang
- Xuanwu Hospital, Capital Medical University; Department of Neurology; Beijing China 100053
| | - Mordechai G Sadowsky
- Wayne State University School of Medicine; Department of Neurological Surgery; Detroit, Michigan USA
| | - Ran Meng
- Xuanwu Hospital, Capital Medical University; Department of Neurology; Beijing China 100053
| | - Yuchuan Ding
- Wayne State University School of Medicine; Department of Neurological Surgery; Detroit, Michigan USA
| | - Xunming Ji
- Xuanwu Hospital, Capital Medical University; Department of Neurosurgery; Beijing China 100053
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35
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Avila-Rodriguez M, Garcia-Segura LM, Hidalgo-Lanussa O, Baez E, Gonzalez J, Barreto GE. Tibolone protects astrocytic cells from glucose deprivation through a mechanism involving estrogen receptor beta and the upregulation of neuroglobin expression. Mol Cell Endocrinol 2016; 433:35-46. [PMID: 27250720 DOI: 10.1016/j.mce.2016.05.024] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/29/2016] [Accepted: 05/28/2016] [Indexed: 10/21/2022]
Abstract
Tibolone, a synthetic steroid used for the prevention of osteoporosis and the treatment of climacteric symptoms in post-menopausal women, may exert tissue selective estrogenic actions acting on estrogen receptors (ERs). We previously showed that tibolone protects human T98G astroglial cells against glucose deprivation (GD). In this study we have explored whether the protective effect of tibolone on these cells is mediated by ERs. Experimental studies showed that both ERα and ERβ were involved in the protection by tibolone on GD cells, being ERβ preferentially involved on these actions over ERα. Tibolone increased viability of GD cells by a mechanism fully blocked by an ERβ antagonist and partially blocked by an ERα antagonist. Furthermore, ERβ inhibition prevented the effect of tibolone on nuclear fragmentation, ROS and mitochondrial membrane potential in GD cells. The protective effect of tibolone was mediated by neuroglobin. Tibolone upregulated neuroglobin in T98G cells and primary mouse astrocytes by a mechanism involving ERβ and neuroglobin silencing prevented the protective action of tibolone on GD cells. In summary, tibolone protects T98G cells by a mechanism involving ERβ and the upregulation of neuroglobin.
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Affiliation(s)
- Marco Avila-Rodriguez
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia; Departamento de Ciencias Clínicas, Facultad de Ciencias de la Salud, Universidad del Tolima, Ibagué, Colombia
| | | | - Oscar Hidalgo-Lanussa
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia
| | - Eliana Baez
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia
| | - Janneth Gonzalez
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia
| | - George E Barreto
- Departamento de Nutrición y Bioquímica, Facultad de Ciencias, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia; Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, Santiago, Chile; Universidad Científica del Sur, Lima, Peru.
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36
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Frumkin K, Bloom AS. Ischemic Conditioning: Implications for Emergency Medicine. Ann Emerg Med 2016; 68:268-74. [DOI: 10.1016/j.annemergmed.2016.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/08/2016] [Accepted: 02/10/2016] [Indexed: 01/22/2023]
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