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Fan YY, Li Y, Tian XY, Wang YJ, Huo J, Guo BL, Chen R, Yang CH, Li Y, Zhang HF, Niu BL, Zhang MS. Delayed Chronic Acidic Postconditioning Improves Poststroke Motor Functional Recovery and Brain Tissue Repair by Activating Proton-Sensing TDAG8. Transl Stroke Res 2024; 15:620-635. [PMID: 36853417 DOI: 10.1007/s12975-023-01143-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/13/2022] [Accepted: 02/17/2023] [Indexed: 03/01/2023]
Abstract
Acidic postconditioning by transient CO2 inhalation applied within minutes after reperfusion has neuroprotective effects in the acute phase of stroke. However, the effects of delayed chronic acidic postconditioning (DCAPC) initiated during the subacute phase of stroke or other acute brain injuries are unknown. Mice received daily DCAPC by inhaling 5%/10%/20% CO2 for various durations (three cycles of 10- or 20-min CO2 inhalation/10-min break) at days 3-7, 7-21, or 3-21 after photothrombotic stroke. Grid-walk, cylinder, and gait tests were used to assess motor function. DCAPC with all CO2 concentrations significantly promoted motor functional recovery, even when DCAPC was delayed for 3-7 days. DCAPC enhanced the puncta density of GAP-43 (a marker of axon growth and regeneration) and synaptophysin (a marker of synaptogenesis) and reduced the amoeboid microglia number, glial scar thickness and mRNA expression of CD16 and CD32 (markers of proinflammatory M1 microglia) compared with those of the stroke group. Cerebral blood flow (CBF) increased in response to DCAPC. Furthermore, the mRNA expression of TDAG8 (a proton-activated G-protein-coupled receptor) was increased during the subacute phase of stroke, while DCAPC effects were blocked by systemic knockout of TDAG8, except for those on CBF. DCAPC reproduced the benefits by re-expressing TDAG8 in the peri-infarct cortex of TDAG8-/- mice infected with HBAAV2/9-CMV-TDAG8-3flag-ZsGreen. Taken together, we first showed that DCAPC promoted functional recovery and brain tissue repair after stroke with a wide therapeutic time window of at least 7 days after stroke. Brain-derived TDAG8 is a direct target of DCAPC that induces neuroreparative effects.
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Affiliation(s)
- Yan-Ying Fan
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China.
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, 030001, China.
| | - Yu Li
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China
| | - Xiao-Ying Tian
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China
| | - Ying-Jing Wang
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China
| | - Jing Huo
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China
| | - Bao-Lu Guo
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China
| | - Ru Chen
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China
| | - Cai-Hong Yang
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China
| | - Yan Li
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China
| | - Hui-Feng Zhang
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China
| | - Bao-Long Niu
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China.
- College of Materials Science and Engineering, Taiyuan University of Technology, Taiyuan, 030024, China.
| | - Ming-Sheng Zhang
- Department of Pharmacology, Basic Medical Sciences Center, Shanxi Medical University, Taiyuan, 030001, China.
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Yan MY, Liu JM, Wu J, Chang Q. Impact of remote ischemic postconditioning on acute ischemic stroke in China: a systematic review and meta-analysis of randomized controlled trials. Syst Rev 2024; 13:141. [PMID: 38816852 PMCID: PMC11138007 DOI: 10.1186/s13643-024-02568-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 05/17/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVE Acute ischemic stroke (AIS) is a significant health burden in China, affecting a sizable portion of the population. Conventional pharmacological treatments frequently fall short of desirable outcomes. Therefore, exploring alternative therapies is crucial. Remote ischemic postconditioning (RIPostC) is a noninvasive and cost-effective adjunctive therapy. This study aimed to investigate the efficacy and safety of RIPostC as an adjunctive therapy for AIS to inform clinical practice. METHODS A comprehensive search was conducted across the PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang, Weipu (VIP), and China Biology Medicine disc (CBM) databases up to October 2023. All included studies underwent bias risk assessment using the Cochrane risk-of-bias assessment tool. The primary outcome measure was the National Institute of Health Stroke Scale (NIHSS), with secondary outcomes including the Barthel index (BI), D-dimer, C-reactive protein (CRP), fibrinogen (FIB), brain-derived neurotrophic factor (BDNF), modified Rankin scale (mRS), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) levels. The data were analyzed using fixed-effects and random-effects models in Review Manager, with mean differences (MDs) and 95% confidence intervals (CIs) calculated for each outcome. The grading of recommendations, assessment, development, and evaluations (GRADE) approach was used to evaluate the level of evidence for each outcome measure. RESULTS This meta-analysis included 38 studies, encompassing 4334 patients. Compared with the control group, the RIPostC group had significantly lower NIHSS scores, serum CRP, D-dimer, IL-6, TNF-α, and FIB levels, and increased BDNF levels. Moreover, it improved the patient's BI and mRS scores. According to the GRADE approach, the quality of evidence for mRS was deemed "moderate," while the NIHSS, BI, and CRP were rated as "low" quality. IL-6, TNF-α, FIB, D-dimer, and BDNF received "very low" quality ratings. CONCLUSION The findings suggest that RIPostC activates endogenous protective mechanisms, providing benefits to patients with AIS.
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Affiliation(s)
- Ming-Yuan Yan
- Beijing University of Chinese Medicine, Beijing, China
| | - Jin-Min Liu
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, 100078, China
| | - Jing Wu
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Qing Chang
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, 100078, China.
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Cui Y, Chen Y, Nguyen TN, Chen H. Duration of Remote Ischemic Conditioning and Outcome in Acute Ischemic Stroke. J Am Heart Assoc 2024; 13:e033609. [PMID: 38533936 PMCID: PMC11179777 DOI: 10.1161/jaha.123.033609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/01/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Remote ischemic conditioning has been found to be effective in improving functional outcomes in acute ischemic stroke. We conducted a post hoc analysis of the RICAMIS (Remote Ischemic Conditioning for Acute Moderate Ischemic Stroke) trial to determine whether long-term remote ischemic conditioning duration after stroke onset is associated with better clinical outcomes in ischemic stroke. METHODS AND RESULTS Patients from the full analysis set were included in this secondary analysis. The primary outcome was the proportion of patients with an excellent functional outcome at 90 days, defined as a modified Rankin Scale score of 0 to 1. Among the 1776 patients, there were 55 patients in the 1 to 7 days remote ischemic conditioning group, 345 in the 8 to 10 days group, 412 in the 11 to 13 days group, 51 in the 14 to 16 days group, and 913 in the control group. Compared with the control group, a significantly higher proportion of excellent functional outcomes at 90 days was found in the 11 to 13 days remote ischemic conditioning group (adjusted absolute difference, 9.1% [95% CI, 3.7%-14.5%]; P =0.001), which was attenuated in the other groups (adjusted absolute difference in the 8-10 days group, 2.0% [95% CI, -4.0% to 8.0%]; P=0.51; adjusted absolute difference in the 14-16 days group, 7.4% [95% CI, -5.8% to 20.5%]; P=0.27), but compared to the control group, there was lower proportion of excellent functional outcomes in the 1 to 7 days group (adjusted absolute difference, -14.4% [95% CI, -27.8% to 0.0%]; P=0.05). CONCLUSIONS Among patients with acute moderate ischemic stroke, a higher likelihood of excellent clinical outcome was found in patients with longer duration of remote ischemic conditioning.
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Affiliation(s)
- Yu Cui
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Yi‐Ning Chen
- Department of OncologyThe First Affiliated Hospital of China Medical UniversityShenyangChina
| | - Thanh N. Nguyen
- Department of NeurologyRadiology, Boston Medical CenterBostonMAUSA
| | - Hui‐Sheng Chen
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
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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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Zhu Y, Li X, Wen D, Huang Z, Yan J, Zhang Z, Wang Y, Guo Z. Remote Ischemic Post-conditioning Reduces Cognitive Impairment in Rats Following Subarachnoid Hemorrhage: Possible Involvement in STAT3/STAT5 Phosphorylation and Th17/Treg Cell Homeostasis. Transl Stroke Res 2024:10.1007/s12975-024-01235-y. [PMID: 38356020 DOI: 10.1007/s12975-024-01235-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/12/2024] [Accepted: 02/06/2024] [Indexed: 02/16/2024]
Abstract
The inflammatory response following subarachnoid hemorrhage (SAH) may lead to Early Brain Injury and subsequently contribute to poor prognosis such as cognitive impairment in patients. Currently, there is a lack of effective strategies for SAH to ameliorate inflammation and improve cognitive impairment in clinical. This study aims to examine the inhibitory impact of remote ischemic post-conditioning (RIPostC) on the body's inflammatory response by regulating Th17/Treg cell homeostasis after SAH. The ultimate goal is to search for potential early treatment targets for SAH. The rat SAH models were made by intravascular puncture of the internal carotid artery. The intervention of RIPostC was administered for three consecutive days immediately after successful modeling. Behavioral experiments including the Morris water maze and Y-maze tests were conducted to assess cognitive functions such as spatial memory, working memory, and learning abilities 2 weeks after successful modeling. The ratio of Th17 cells and Treg cells in the blood was detected using flow cytometry. Immunofluorescence was used to observe the infiltration of neutrophils into the brain. Signal transducers and activators of transcription 5 (STAT5) and signal transducers and activators of transcription 3 (STAT3) phosphorylation levels, receptor-related orphan receptor gamma-t (RORγt), and forkhead box protein P3 (Foxp3) levels were detected by Western blot. The levels of anti-inflammatory factors (IL-2, IL-10, IL-5, etc.) and pro-inflammatory factors (IL-6, IL-17, IL-18, TNF-α, IL-14, etc.) in blood were detected using Luminex Liquid Suspension Chip Assay. RIPostC significantly improved the cognitive impairment caused by SAH in rats. The results showed that infiltration of Th17 cells and neutrophils into brain tissue increased after SAH, leading to the release of pro-inflammatory factors (IL-6, IL-17, IL-18, and TNF-α). This response can be inhibited by RIPostC. Additionally, RIPostC facilitates the transfer of Treg from blood to the brain and triggers the release of anti-inflammatory (IL-2, IL-10, and IL-5) factors to suppress the inflammation following SAH. Finally, it was found that RIPostC increased the phosphorylation of STAT5 while decreasing the phosphorylation of STAT3. RIPostC reduces inflammation after SAH by partially balancing Th17/Treg cell homeostasis, which may be related to downregulation of STAT3 and upregulation of STAT5 phosphorylation, which ultimately alleviates cognitive impairment in rats. Targeting Th17/Treg cell homeostasis may be a promising strategy for early SAH treatment.
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Affiliation(s)
- Yajun Zhu
- The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Xiaoguo Li
- The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - DaoChen Wen
- The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Zichao Huang
- The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Jin Yan
- The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Zhaosi Zhang
- The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Yingwen Wang
- The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Zongduo Guo
- The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China.
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Furman M, Sihotsky V, Virag M, Kopolovets I, Nemethova M, Mucha R. Quantitative analysis of selected genetic markers of induced brain stroke ischemic tolerance detected in human blood. Brain Res 2023; 1821:148590. [PMID: 37739332 DOI: 10.1016/j.brainres.2023.148590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 09/24/2023]
Abstract
A brain stroke is a serious disease and the second leading cause of death in the European Union. Carotid stenosis accounts for 15% of all ischemic cerebral strokes. However, there is currently no effective screening for carotid disease. Analysis of the DNA from peripheral blood is increasingly being used for several disease diagnoses. The potentially beneficial therapeutic method of inducing tissue tolerance to ischemia has so far been studied mainly in animal models. The aim of this study is to investigate changes in the gene expression of selected markers of brain ischemia during carotid endarterectomy, considered in this study as an activator of ischemic tolerance. During the carotid endarterectomy, there is a short-term occlusion of the internal carotid artery. Using the RT-qPCR method, we detected changes in the early identified gene markers of brain ischemia (ADM, CDKN1A, GADD45G, IL6, TM4SF1) in peripheral blood during sub lethal cerebral ischemia caused by carotid endarterectomy. Patients underwenting surgical procedure were divided into three groups: asymptomatic, symptomatic, and those who underwent carotid endarterectomy after an acute stroke. The results were compared to a negative/control group. Carotid endarterectomy had an impact on the expression of all monitored biomarkers. We observed statistically significant changes (p value 0.05-0.001) when comparing the groups among themselves, as well as the presence of ischemic tolerance of brain tissue to ischemic attacks. In conclusion, ADM, GADD45G, and TM4SF1 were affected in symptomatic patients, GADD45G and IL6 in acute patients, and CDKN1A and ADM in asymptomatic group after application of carotid endarterectomy.
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Affiliation(s)
- Marek Furman
- Institute of Neurobiology of Biomedical Research Center, Slovak Academy of Sciences, Soltesovej 4, 040 01 Kosice, Slovakia
| | - Vladimir Sihotsky
- Eastern Slovak Institute of Cardiovascular Diseases and Faculty of Medicine, Pavol Jozef Safarik University, Kosice, Ondavska 8, 040 01 Kosice, Slovakia
| | - Michal Virag
- Eastern Slovak Institute of Cardiovascular Diseases and Faculty of Medicine, Pavol Jozef Safarik University, Kosice, Ondavska 8, 040 01 Kosice, Slovakia
| | - Ivan Kopolovets
- Eastern Slovak Institute of Cardiovascular Diseases and Faculty of Medicine, Pavol Jozef Safarik University, Kosice, Ondavska 8, 040 01 Kosice, Slovakia
| | - Miroslava Nemethova
- Institute of Neurobiology of Biomedical Research Center, Slovak Academy of Sciences, Soltesovej 4, 040 01 Kosice, Slovakia
| | - Rastislav Mucha
- Institute of Neurobiology of Biomedical Research Center, Slovak Academy of Sciences, Soltesovej 4, 040 01 Kosice, Slovakia.
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Cui Y, Yuan ZM, Liu QY, Wang YJ, Chen HS. Remote Ischemic Conditioning and Outcomes in Acute Ischemic Stroke With Versus Without Large Artery Atherosclerosis. Stroke 2023; 54:3165-3168. [PMID: 37850359 DOI: 10.1161/strokeaha.123.045040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/22/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND RICAMIS trial (The Remote Ischemic Conditioning for Acute Moderate Ischemic Stroke) has demonstrated efficacy of remote ischemic conditioning (RIC) in acute ischemic stroke. We conducted a post hoc analysis of RICAMIS to investigate whether large artery atherosclerosis (LAA) subtype contributed to the outcomes. METHODS This is a post hoc analysis of the RICAMIS trial. Patients randomized to RIC group and Control group in full analysis set of RICAMIS were classified into LAA and non-LAA subtypes. The primary outcome was excellent functional outcome at 90 days, defined as modified Rankin Scale score of 0 to 1. Compared with patients receiving usual care, we investigated the association of RIC effect with outcomes in stroke subtypes and the interaction between RIC effect and stroke subtypes. The primary analysis was adjusted analysis. RESULTS Among 1773 patients, 516 were assigned to LAA subtype (229 in the RIC group and 287 in the control group) and 1257 to non-LAA subtype (633 in the RIC group and 624 in the control group). Median age was 65 years, and 34.2% were women. A higher proportion of primary outcome was found to be associated with RIC treatment in LAA subtype (adjusted risk difference, 11.4% [95% CI, 3.6%-19.2%]; P=0.004), but not in non-LAA subtype (adjusted risk difference, 4.1% [95% CI, -1.1% to 9.3%]; P=0.12). There was no significant interaction between RIC effect and stroke subtypes (P=0.12). CONCLUSIONS Patients with LAA subtype may benefit from RIC after stroke with respect to excellent functional outcome at 90 days. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03740971.
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Affiliation(s)
- Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China (Y.C., Q.-Y.L., Y.-J.W., H.-S.C.)
| | - Zhi-Mei Yuan
- Department of Neurology, Tonghua Vascular Disease Hospital (Dongchang District People's Hospital), Tonghua, China (Z.-M.Y.)
| | - Quan-Ying Liu
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China (Y.C., Q.-Y.L., Y.-J.W., H.-S.C.)
| | - Ying-Jia Wang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China (Y.C., Q.-Y.L., Y.-J.W., H.-S.C.)
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China (Y.C., Q.-Y.L., Y.-J.W., H.-S.C.)
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Qiao H, Xu Q, Xu Y, Zhao Y, He N, Tang J, Zhao J, Liu Y. Molecular chaperones in stroke-induced immunosuppression. Neural Regen Res 2023; 18:2638-2644. [PMID: 37449602 DOI: 10.4103/1673-5374.373678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Stroke-induced immunosuppression is a process that leads to peripheral suppression of the immune system after a stroke and belongs to the central nervous system injury-induced immunosuppressive syndrome. Stroke-induced immunosuppression leads to increased susceptibility to post-stroke infections, such as urinary tract infections and stroke-associated pneumonia, worsening prognosis. Molecular chaperones are a large class of proteins that are able to maintain proteostasis by directing the folding of nascent polypeptide chains, refolding misfolded proteins, and targeting misfolded proteins for degradation. Various molecular chaperones have been shown to play roles in stroke-induced immunosuppression by modulating the activity of other molecular chaperones, cochaperones, and their associated pathways. This review summarizes the role of molecular chaperones in stroke-induced immunosuppression and discusses new approaches to restore host immune defense after stroke.
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Affiliation(s)
- Haoduo Qiao
- Department of Neurosurgery, Xiangya Hospital, Central South University; Department of Pathophysiology, Xiangya School of Medicine, Central South University; Sepsis Translational Medicine Key Laboratory of Hunan Province; National Medicine Functional Experimental Teaching Center, Changsha, Hunan Province, China
| | - Qing Xu
- Department of Neurosurgery, Xiangya Hospital, Central South University; Department of Pathophysiology, Xiangya School of Medicine, Central South University; Sepsis Translational Medicine Key Laboratory of Hunan Province; National Medicine Functional Experimental Teaching Center, Changsha, Hunan Province, China
| | - Yunfei Xu
- Department of Neurosurgery, Xiangya Hospital, Central South University; Department of Pathophysiology, Xiangya School of Medicine, Central South University; Sepsis Translational Medicine Key Laboratory of Hunan Province; National Medicine Functional Experimental Teaching Center, Changsha, Hunan Province, China
| | - Yao Zhao
- Department of Neurosurgery, Xiangya Hospital, Central South University; Department of Pathophysiology, Xiangya School of Medicine, Central South University; Sepsis Translational Medicine Key Laboratory of Hunan Province; National Medicine Functional Experimental Teaching Center, Changsha, Hunan Province, China
| | - Nina He
- Department of Neurosurgery, Xiangya Hospital, Central South University; Department of Pathophysiology, Xiangya School of Medicine, Central South University; Sepsis Translational Medicine Key Laboratory of Hunan Province; National Medicine Functional Experimental Teaching Center, Changsha, Hunan Province, China
| | - Jie Tang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Jie Zhao
- Department of Neurosurgery, Xiangya Hospital, Central South University; Department of Pathophysiology, Xiangya School of Medicine, Central South University; Sepsis Translational Medicine Key Laboratory of Hunan Province; National Medicine Functional Experimental Teaching Center, Changsha, Hunan Province, China
| | - Ying Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University; Department of Pathophysiology, Xiangya School of Medicine, Central South University; Sepsis Translational Medicine Key Laboratory of Hunan Province; National Medicine Functional Experimental Teaching Center, Changsha, Hunan Province, China
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Tong Y, Ding Y, Han Z, Duan H, Geng X. Optimal rehabilitation strategies for early postacute stroke recovery: An ongoing inquiry. Brain Circ 2023; 9:201-204. [PMID: 38284113 PMCID: PMC10821682 DOI: 10.4103/bc.bc_33_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/26/2023] [Accepted: 08/29/2023] [Indexed: 01/30/2024] Open
Abstract
Early rehabilitation is crucial in reducing stroke-related disability, but the optimal training model remains unclear. We conducted a trial comparing different initiation timings and intensities of mobilization strategies after stroke. Results showed that early intensive mobilization had favorable outcomes at 3 months post-stroke, while very early intensive mobilization had poorer chances of favorable outcomes. Our investigation into brain injury mechanisms induced by very early exercise within 24 hours of stroke onset aligned with guidelines advising against high-dose very early mobilization. Additionally, we are studying the effects of various exercise intensities and frequencies on early stroke rehabilitation. Integrated rehabilitation models, such as combining remote ischemic conditioning (RIC) with exercise (RICE), hold promise. Our study found RICE to be safe and feasible for early rehabilitation of acute ischemic stroke patients, and further research is underway to determine its efficacy in a larger sample size. Despite extensive research, identifying the most effective early recovery strategies remains a complex challenge, necessitating ongoing work in the field of early rehabilitation after stroke.
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Affiliation(s)
- Yanna Tong
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Zhenzhen Han
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Honglian Duan
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
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Cui Y, Chen YN, Nguyen TN, Chen HS. Time from Onset to Remote Ischemic Conditioning and Clinical Outcome After Acute Moderate Ischemic Stroke. Ann Neurol 2023; 94:561-571. [PMID: 37253659 DOI: 10.1002/ana.26715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 05/06/2023] [Accepted: 05/13/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVE We conducted a post hoc exploratory analysis of Remote Ischemic Conditioning for Acute Moderate Ischemic Stroke (RICAMIS) to determine whether early remote ischemic conditioning (RIC) initiation after stroke onset was associated with clinical outcome in patients with acute moderate ischemic stroke. METHODS In RICAMIS, patients receiving RIC treatment in the intention-to-treat analysis were divided into 2 groups based on onset-to-treatment time (OTT): early RIC group (OTT ≤ 24 hours) and late RIC group (OTT 24-48 hours). Patients receiving usual care without RIC treatment from intention-to-treat analysis were assigned as the control group. The primary outcome was excellent functional outcome at 90 days. RESULTS Among 1,776 patients from intention-to-treat analysis, 387 were in the early RIC group, 476 in the late RIC group, and 913 in the control group. In the post hoc exploratory analysis, a higher proportion of excellent functional outcome was found in the early RIC versus control group (adjusted absolute difference = 8.1%, 95% confidence interval [CI] = 2.5%-13.8%, p = 0.005), but no difference in outcomes was detected in the late RIC versus control group (adjusted absolute difference = 3.3%, 95% CI = -2.1% to 8.6%, p = 0.23), or in the early RIC versus late RIC group (adjusted absolute difference = 5.0%, 95% CI = -1.3% to 11.2%, p = 0.12). Similar results were found in the per-protocol analysis. INTERPRETATION Among patients with acute moderate ischemic stroke who are not candidates for intravenous thrombolysis or endovascular therapy, early RIC initiation within 24 hours of onset may be associated with higher likelihood of excellent clinical outcome. ANN NEUROL 2023;94:561-571.
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Affiliation(s)
- Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi-Ning Chen
- Department of Oncology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Thanh N Nguyen
- Departments of Neurology and Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
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11
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Xu Y, Wang Y, Ji X. Immune and inflammatory mechanism of remote ischemic conditioning: A narrative review. Brain Circ 2023; 9:77-87. [PMID: 37576576 PMCID: PMC10419737 DOI: 10.4103/bc.bc_57_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 02/06/2023] [Accepted: 02/17/2023] [Indexed: 08/15/2023] Open
Abstract
The benefits of remote ischemic conditioning (RIC) on multiple organs have been extensively investigated. According to existing research, suppressing the immune inflammatory response is an essential mechanism of RIC. Based on the extensive effects of RIC on cardiovascular and cerebrovascular diseases, this article reviews the immune and inflammatory mechanisms of RIC and summarizes the effects of RIC on immunity and inflammation from three perspectives: (1) the mechanisms of the impact of RIC on inflammation and immunity; (2) evidence of the effects of RIC on immune and inflammatory processes in ischaemic stroke; and (3) possible future applications of this effect, especially in systemic infectious diseases such as sepsis and sepsis-associated encephalopathy. This review explores the possibility of using RIC as a treatment in more inflammation-related diseases, which will provide new ideas for the treatment of this kind of disease.
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Affiliation(s)
- Yi Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- China-America Institute of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- China-America Institute of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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12
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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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13
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Jiang G, Li X, Liu M, Li H, Shen H, liao J, You W, Fang Q, Chen G. Remote ischemic postconditioning ameliorates stroke injury via the SDF-1α/CXCR4 signaling axis in rats. Brain Res Bull 2023; 197:31-41. [PMID: 36990325 DOI: 10.1016/j.brainresbull.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/14/2023] [Accepted: 03/26/2023] [Indexed: 03/29/2023]
Abstract
Remote Ischemic Postconditioning (RIPostC) has become a research hotspot due to its protective effect on the brain in clinical studies related to ischemic stroke. The purpose of this study is to investigate the protective effect of RIPostC after ischemic stroke in rats. The middle cerebral artery occlusion/reperfusion (MCAO/R) model was established by the wire embolization method. RIPostC was obtained by inducing temporary ischemia in the hind limbs of rats. First, based on the results of short-term behavioral measures and long-term neurological function experiments, RIPostC was found to have a protective effect on the MCAO/R model and to improve neurological recovery in rats. Compared to the sham group, RIPostC upregulated the expression levels of C-X-C motif chemokine receptor 4(CXCR4) in the brain and stromal cell-derived factor-1(SDF-1α) in peripheral blood. In addition, RIPostC upregulated CXCR4 expression on CD34+ stem cells in peripheral blood in flow cytometric assays. Meanwhile, according to the results of EdU/DCX co-staining and CD31 staining, it was found that the effect of RIPostC on ameliorating brain injury via SDF-1α/CXCR4 signaling axis may be associated with vascular neogenesis. Finally, after inhibiting the SDF-1α/CXCR4 signaling axis using AMD3100(Plerixafor), we found that the neuroprotective effect of RIPostC was diminished. Taken together, RIPostC can improve neurobehavioral damage induced by MCAO/R in rats, and its mechanism may be related to SDF-1α/CXCR4 signaling axis. Therefore, RIPostC can be used as an intervention strategy for stroke. SDF-1α/CXCR4 signaling axis can also be a potential target for intervention.
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14
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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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15
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Chen HS, Cui Y, Li XQ, Wang XH, Ma YT, Zhao Y, Han J, Deng CQ, Hong M, Bao Y, Zhao LH, Yan TG, Zou RL, Wang H, Li Z, Wan LS, Zhang L, Wang LQ, Guo LY, Li MN, Wang DQ, Zhang Q, Chang DW, Zhang HL, Sun J, Meng C, Zhang ZH, Shen LY, Ma L, Wang GC, Li RH, Zhang L, Bi C, Wang LY, Wang DL. Effect of Remote Ischemic Conditioning vs Usual Care on Neurologic Function in Patients With Acute Moderate Ischemic Stroke: The RICAMIS Randomized Clinical Trial. JAMA 2022; 328:627-636. [PMID: 35972485 PMCID: PMC9382441 DOI: 10.1001/jama.2022.13123] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Preclinical and clinical studies have suggested a neuroprotective effect of remote ischemic conditioning (RIC), which involves repeated occlusion/release cycles on bilateral upper limb arteries; however, robust evidence in patients with ischemic stroke is lacking. OBJECTIVE To assess the efficacy of RIC for acute moderate ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This multicenter, open-label, blinded-end point, randomized clinical trial including 1893 patients with acute moderate ischemic stroke was conducted at 55 hospitals in China from December 26, 2018, through January 19, 2021, and the date of final follow-up was April 19, 2021. INTERVENTIONS Eligible patients were randomly assigned within 48 hours after symptom onset to receive treatment with RIC (using a pneumatic electronic device and consisting of 5 cycles of cuff inflation for 5 minutes and deflation for 5 minutes to the bilateral upper limbs to 200 mm Hg) for 10 to 14 days as an adjunct to guideline-based treatment (n = 922) or guideline-based treatment alone (n = 971). MAIN OUTCOMES AND MEASURES The primary end point was excellent functional outcome at 90 days, defined as a modified Rankin Scale score of 0 to 1. All end points had blinded assessment and were analyzed on a full analysis set. RESULTS Among 1893 eligible patients with acute moderate ischemic stroke who were randomized (mean [SD] age, 65 [10.3] years; 606 women [34.1%]), 1776 (93.8%) completed the trial. The number with excellent functional outcome at 90 days was 582 (67.4%) in the RIC group and 566 (62.0%) in the control group (risk difference, 5.4% [95% CI, 1.0%-9.9%]; odds ratio, 1.27 [95% CI, 1.05-1.54]; P = .02). The proportion of patients with any adverse events was 6.8% (59/863) in the RIC group and 5.6% (51/913) in the control group. CONCLUSIONS AND RELEVANCE Among adults with acute moderate ischemic stroke, treatment with remote ischemic conditioning compared with usual care significantly increased the likelihood of excellent neurologic function at 90 days. However, these findings require replication in another trial before concluding efficacy for this intervention. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03740971.
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Affiliation(s)
- Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Xin-Hong Wang
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yu-Tong Ma
- Department of Neurology, Beipiao Central Hospital, Beipiao, China
| | - Yong Zhao
- Department of Neurology, Haicheng Chinese Medicine Hospital, Haicheng, China
| | - Jing Han
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Chang-Qing Deng
- Department of Neurology, Dandong Central Hospital, Dandong, China
| | - Mei Hong
- Department of Neurology, China Railway 19th Bureau Group Central Hospital, Liaoyang, China
| | - Ying Bao
- Department of Neurology, Fuxin Second People’s Hospital, Fuxin, China
| | - Li-Hong Zhao
- Department of Neurology, Dandong People’s Hospital, Dandong, China
| | - Ting-Guang Yan
- Department of Neurology, Chaoyang Central Hospital, Chaoyang, China
| | - Ren-Lin Zou
- Department of Neurology, Wafangdian Third Hospital, Dalian, China
| | - Hui Wang
- Department of Neurology, Chinese People’s Liberation Army 230 Hospital, Dandong, China
| | - Zhuo Li
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Li-Shu Wan
- Department of Neurology, Dandong First Hospital, Dandong, China
| | - Li Zhang
- Department of Neurology, Suizhong County Hospital, Huludao, China
| | - Lian-Qiang Wang
- Department of Neurology, Liaoyang County Stroke Hospital, Liaoyang, China
| | - Li-Yan Guo
- Department of Neurology, Fushun Second Hospital, Fushun, China
| | - Ming-Nan Li
- Department of Neurology, Huanren Manchu Autonomous County People’s Hospital, Benxi, China
| | - Dong-Qing Wang
- Department of Neurology, Panjin People’s Hospital, Panjin, China
| | - Qiang Zhang
- Department of Neurology, Fushun Central Hospital, Fushun, China
| | - Da-Wei Chang
- Department of Neurology, Sujiatun Stroke Hospital, Shenyang, China
| | - Hong-Li Zhang
- Department of Neurology, Taian County Chinese Medicine Hospital, Anshan, China
| | - Jing Sun
- Department of Neurology, Anshan Hospital, The First Affiliated Hospital of China Medical University, Anshan, China
| | - Chong Meng
- Department of Neurology, Liaoyang County Central Hospital, Liaoyang, China
| | - Zai-Hui Zhang
- Department of Neurology, Xiuyan County Central Hospital, Anshan, China
| | - Li-Ying Shen
- Department of Neurology, Tieling County Central Hospital, Tieling, China
| | - Li Ma
- Department of Neurology, The Affiliated Central Hospital of Shenyang Medical College, Shenyang, China
| | - Gui-Chun Wang
- Department of Neurology, Changtu County Central Hospital, Tieling, China
| | - Run-Hui Li
- Department of Neurology, The Affiliated Central Hospital of Shenyang Medical College, Shenyang, China
| | - Ling Zhang
- Department of Neurology, Dengta Central Hospital, Dengta, China
| | - Cheng Bi
- Department of Neurology, Dandong Central Hospital, Dandong, China
| | - Li-Yun Wang
- Department of Neurology, Liaoyang Petrochemical General Hospital, Liaoyang, China
| | - Duo-Lao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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16
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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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17
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Ma W, Zhu K, Yin L, Yang J, Zhang J, Wu H, Liu K, Li C, Liu W, Guo J, Li L. Effects of ischemic postconditioning and long non-coding RNAs in ischemic stroke. Bioengineered 2022; 13:14799-14814. [PMID: 36420646 PMCID: PMC9704383 DOI: 10.1080/21655979.2022.2108266] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Stroke is a main cause of disability and death among adults in China, and acute ischemic stroke accounts for 80% of cases. The key to ischemic stroke treatment is to recanalize the blocked blood vessels. However, more than 90% of patients cannot receive effective treatment within an appropriate time, and delayed recanalization of blood vessels causes reperfusion injury. Recent research has revealed that ischemic postconditioning has a neuroprotective effect on the brain, but the mechanism has not been fully clarified. Long non-coding RNAs (lncRNAs) have previously been associated with ischemic reperfusion injury in ischemic stroke. LncRNAs regulate important cellular and molecular events through a variety of mechanisms, but a comprehensive analysis of potential lncRNAs involved in the brain protection produced by ischemic postconditioning has not been conducted. In this review, we summarize the common mechanisms of cerebral injury in ischemic stroke and the effect of ischemic postconditioning, and we describe the potential mechanisms of some lncRNAs associated with ischemic stroke.
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Affiliation(s)
- Wei Ma
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, China
| | - Kewei Zhu
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, China
| | - Luwei Yin
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, China
| | - Jinwei Yang
- Second Department of General Surgery, First People’s Hospital of Yunnan Province, Kunming, China
| | - Jinfen Zhang
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, China
| | - Hongjie Wu
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, China
| | - Kuangpin Liu
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, China
| | - Chunyan Li
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, China
| | - Wei Liu
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, China
| | - Jianhui Guo
- Second Department of General Surgery, First People’s Hospital of Yunnan Province, Kunming, China,Jianhui Guo Second Department of General Surgery, First People’s Hospital of Yunnan Province, Kunming 650034, Yunnan, China
| | - Liyan Li
- Institute of Neuroscience, Faculty of Basic Medical Science, Kunming Medical University, Kunming, China,CONTACT Liyan Li Institute of Neurosicence, Faculty of Basic Medical Science, Kunming Medical University, Kunming 650500, Yunnan, China
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18
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Jin X, Li P, Michalski D, Li S, Zhang Y, Jolkkonen J, Cui L, Didwischus N, Xuan W, Boltze J. Perioperative stroke: A perspective on challenges and opportunities for experimental treatment and diagnostic strategies. CNS Neurosci Ther 2022; 28:497-509. [PMID: 35224865 PMCID: PMC8928912 DOI: 10.1111/cns.13816] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/31/2022] [Accepted: 02/04/2022] [Indexed: 02/06/2023] Open
Abstract
Perioperative stroke is an ischemic or hemorrhagic cerebral event during or up to 30 days after surgery. It is a feared condition due to a relatively high incidence, difficulties in timely detection, and unfavorable outcome compared to spontaneously occurring stroke. Recent preclinical data suggest that specific pathophysiological mechanisms such as aggravated neuroinflammation contribute to the detrimental impact of perioperative stroke. Conventional treatment options are limited in the perioperative setting due to difficult diagnosis and medications affecting coagulation in may cases. On the contrary, the chance to anticipate cerebrovascular events at the time of surgery may pave the way for prevention strategies. This review provides an overview on perioperative stroke incidence, related problems, and underlying pathophysiological mechanisms. Based on this analysis, we assess experimental stroke treatments including neuroprotective approaches, cell therapies, and conditioning medicine strategies regarding their potential use in perioperative stroke. Interestingly, the specific aspects of perioperative stroke might enable a more effective application of experimental treatment strategies such as classical neuroprotection whereas others including cell therapies may be of limited use. We also discuss experimental diagnostic options for perioperative stroke augmenting classical clinical and imaging stroke diagnosis. While some experimental stroke treatments may have specific advantages in perioperative stroke, the paucity of established guidelines or multicenter clinical research initiatives currently limits their thorough investigation.
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Affiliation(s)
- Xia Jin
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Peiying Li
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | | | - Shen Li
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yueman Zhang
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Jukka Jolkkonen
- Department of Neurology and A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Lili Cui
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Nadine Didwischus
- School of Life Sciences, University of Warwick, Coventry, UK.,Department of Radiology, University of Pittsburgh, Pittsburgh, USA.,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Wei Xuan
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Johannes Boltze
- School of Life Sciences, University of Warwick, Coventry, UK
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Kim J, Franke WD, Lang JA. Delayed Cutaneous Microvascular Responses With Non-consecutive 3 Days of Remote Ischemic Preconditioning. Front Physiol 2022; 13:852966. [PMID: 35360244 PMCID: PMC8964107 DOI: 10.3389/fphys.2022.852966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/15/2022] [Indexed: 12/19/2022] Open
Abstract
The optimal frequency and duration of remote ischemic preconditioning (RIPC) that augments microvascular function is unknown. A single bout of RIPC increases cutaneous endothelial function for ∼48 h, whereas 1 week of daily RIPC bouts improves more sustained endothelium-independent function. We hypothesized that 3 days of RIPC separated by rest days (3QOD RIPC) would result in sustained increases in both endothelium-dependent and endothelium-independent functions. Cutaneous microvascular function was assessed in 13 healthy young participants (aged 20.5 ± 3.9 years; 5 males, 8 females) before 3QOD and then 24, 48, and 72 h and a week after 3QOD. RIPC consisted of four repetitions of 5 min of blood flow occlusion separated by 5 min of reperfusion. Skin blood flow responses to local heating (Tloc = 42°C), acetylcholine (Ach), and sodium nitroprusside (SNP) were measured using laser speckle contrast imaging and expressed as cutaneous vascular conductance (CVC = PU⋅mmHg–1). Local heating-mediated vasodilation was increased 72 h after 3QOD and the increased responsivity persisted a week later (1.08 ± 0.24 vs. 1.34 ± 0.46, 1.21 ± 0.36 PU⋅mmHg–1; ΔCVC, pre-RIPC vs. 72 h, a week after 3QOD; P = 0.054). Ach-induced cutaneous vasodilation increased a week after 3QOD (0.73 ± 0.41 vs. 0.95 ± 0.49 PU⋅mmHg–1; ΔCVC, pre-RIPC vs. a week after 3QOD; P < 0.05). SNP-induced cutaneous vasodilation increased 24 h after 3QOD (0.47 ± 0.28 vs. 0.63 ± 0.35 PU⋅mmHg–1; ΔCVC, pre-RIPC vs. 24 h; P < 0.05), but this change did not persist thereafter. Thus, 3QOD induced sustained improvement in endothelium-dependent vasodilation but was not sufficient to sustain increases in endothelium-independent vasodilation.
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Affiliation(s)
- Jahyun Kim
- Department of Kinesiology, California State University, Bakersfield, Bakersfield, CA, United States
| | - Warren D. Franke
- Department of Kinesiology, Iowa State University, Ames, IA, United States
| | - James A. Lang
- Department of Kinesiology, Iowa State University, Ames, IA, United States
- *Correspondence: James A. Lang,
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Zhang B, Zhao W, Ma H, Zhang Y, Che R, Bian T, Yan H, Xu J, Wang L, Yu W, Liu J, Song H, Duan J, Chang H, Ma Q, Zhang Q, Ji X. Remote Ischemic Conditioning in the Prevention for Stroke-Associated Pneumonia: A Pilot Randomized Controlled Trial. Front Neurol 2022; 12:723342. [PMID: 35185744 PMCID: PMC8850400 DOI: 10.3389/fneur.2021.723342] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 12/21/2021] [Indexed: 01/02/2023] Open
Abstract
BackgroundDespite the continuing effort in investigating the preventive therapies for stroke-associated pneumonia (SAP), which is closely associated with unfavorable outcomes, conclusively effective therapy for the prevention of SAP is still lacking. Remote ischemic conditioning (RIC) has been proven to improve the survival in the sepsis model and inflammatory responses have been indicated as important mechanisms involved in the multi-organ protection effect of RIC. This study aimed to assess the safety and the preliminary efficacy of RIC in the prevention of SAP in patients with acute ischemic stroke.MethodsWe performed a proof-of-concept, pilot open-label randomized controlled trial. Eligible patients (age > 18 years) within 48 h after stroke onset between March 2019 and October 2019 with acute ischemic stroke were randomly allocated (1:1) to the RIC group and the control group. All participants received standard medical therapy. Patients in the RIC group underwent RIC twice daily for 6 consecutive days. The safety outcome included any adverse events associated with RIC procedures. The efficacy outcome included the incidence of SAP, changes of immunological profiles including mHLA-DR, TLR-2, and TLR-4 as well as other plasma parameters from routine blood tests.ResultsIn total, 46 patients aged 63.1 ± 12.5 years, were recruited (23 in each group). Overall, 19 patients in the RIC group and 22 patients in the control group completed this study. No severe adverse event was attributed to RIC procedures. The incidence of SAP was lower in the remote ischemic conditioning group (2 patients [10.5%]) than that in the control group (6 patients [27.3%]), but no significant difference was detected in both univariate and multivariate analysis (p = 0.249 and adjusted p = 0.666). No significance has been found in this pilot trial in the level of immunological profiles HLA-DR, TLR4 and TLR2 expressed on monocytes as well as blood parameters tested through routine blood tests between the two groups (p > 0.05). The IL-6 and IL-1β levels at day 5 after admission in the RIC group were lower than those in the control group (p < 0.05).InterpretationThis proof-of-concept pilot randomized controlled trial was to investigate RIC as a prevention method for SAP. Remote ischemic conditioning is safe in the prevention of SAP in patients with acute ischemic stroke. The preventive effect of RIC on SAP should be further validated in future studies.
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Affiliation(s)
- Bowei Zhang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Hongrui Ma
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yunzhou Zhang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Ruiwen Che
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Tingting Bian
- Department of Neurology, Beijing Fengtai You'anmen Hospital, Beijing, China
| | - Heli Yan
- Department of Neurology, Beijing Fengtai You'anmen Hospital, Beijing, China
| | - Jiali Xu
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Lin Wang
- Department of Hematology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wantong Yu
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Jia Liu
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Jiangang Duan
- Department of Emergency, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Hong Chang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qian Zhang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xunming Ji
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
- *Correspondence: Xunming Ji
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21
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Modifications of gene expression detected in peripheral blood after brain ischemia treated with remote postconditioning. Mol Biol Rep 2021; 49:477-485. [PMID: 34766231 DOI: 10.1007/s11033-021-06899-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/29/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND A stroke is an acute damage to a certain area of a nerve tissue of the brain. In developed countries, it ranks second among the most often causes of death and is also the leading cause of disability. Recent findings emphasize the significant neuroprotective effect of conditioning on the course and rate of recovery after ischemic attack; however the molecular mechanism of ischemic tolerance induced by conditioning is still not completely explored. METHODS AND RESULTS The purpose of this study is an identification of changes in gene expression induced by stimulation of reaction cascades after activation of the neuroprotective mechanism using an experimental rat model of global ischemia. The induction of neuroprotective cascades was stimulated by the application of early and delayed form of remote ischemic postconditioning. The quantitative qRT-PCR method was used to assess the rate of change in ADM, BDNF, CDKN1A, CREB, GADD45G, IL6, nNOS, and TM4SF1 gene expression levels 72 h after ischemic attack. The detected results confirm the neuroprotective effect of both forms of postconditioning. Participation of neuroprotection-related gene expression changes was observed once as an early one (CREB, GADD45G), once as a delayed one (ADM, IL6), or both (BDNF, CDKN1A, nNOS, TM4SF1) postconditioning forms, depending on the particular gene. CONCLUSIONS Our results characterize impact of ischemic tolerance on the molecular level. We predict ischemic tolerance to be consisted of complex combination of early and delayed remote postconditioning.
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22
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Wills M, Ding Y. Mini-review (Part II): A clinical consideration on exercise and ischemic conditioning in stroke rehabilitation. Brain Circ 2021; 7:225-229. [PMID: 35071837 PMCID: PMC8757501 DOI: 10.4103/bc.bc_56_21] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 11/04/2022] Open
Abstract
Exercise therapy is commonly recommended and is often considered to be the gold standard of rehabilitation in patients with ischemic stroke. However, implementation and standardization of exercise therapy are challenging as patients vary in their abilities, disabilities, and willingness to participate in exercise rehabilitation after a cerebrovascular event. Remote ischemic conditioning (RIC) is a more passive and accessible therapy that, although remains in its infancy, has the potential to confer similar neuroprotective effects as exercise. In the previously published Part I of this Mini Review, we examined the biochemical evidence for exercise and RIC and noted that the in vitro results may be misleading outside of the context of clinical application. In the present review, we investigate the various clinical parameters by which exercise and RIC therapy may be most beneficial to ischemic stroke victims. We also extend our discussion to consider the therapeutic combination of RIC and exercise therapy to maximize functional outcomes after stroke.
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Affiliation(s)
- Melissa Wills
- 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
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23
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Wang Q, Wills M, Li F, Geng X, Ding Y. Remote ischemic conditioning with exercise (RICE) promotes functional rehabilitation following ischemic stroke. Neurol Res 2021; 43:874-883. [PMID: 34151756 DOI: 10.1080/01616412.2021.1939489] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: Exercise is an essential rehabilitative strategy after stroke butits implementation is limited as its very early use can exacerbate damage and is restricted by patient disability. Remote Ischemic Conditioning (RIC) is a safe alternative for post-stroke neuroprotetion. The present study investigated the neurorehabilitative benefits of early RIC followed by exercise (RICE) therapy.Methods: 48 adult male Sprague-Dawley rats were divided into groups: 1) sham, 2) stroke, 3) stroke with RICE at day 3 (RIC 6 hours after reperfusion followed by exercise days 3 to 28), 4) stroke with exercise at day 3 (exercise days 3 to 28), and 5) stroke with RICE at day 1 (RIC 6 hours after reperfusion followed by exercise days 1 to 28), 6) stroke with exercise at day 1 (exercise days 1 to 28 after reperfusion). Long-term functional outcomes were determined by grid walk, rota-rod, adhesive tape touch, and Morris water maze. Levels of mRNA and proteins of neuroplasticity, synaptogenesis, and angiogenesis, were determined.Results: As compared to exercise only, animals that underwent RICE had significant improvements in functional outcomes after stroke. These improvements were most significant in groups that had the later initiation of exercise. In addition, all treatment groups showed significant increases in mRNA and protein expression of the target molecules for neuroplasticity, synaptogenesis, and angiogenesis, while further significant increases were observed after RICE following ischemic stroke.Conclusions: RICE, a novel therapy that supplements RIC prior to exercise, is superiorly effective in inducing rehabilitation after stroke as compared to the traditional exercise monotherapy rehabilitation in rats with ischemic brain injury.
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Affiliation(s)
- Qingzhu Wang
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Melissa Wills
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Fengwu Li
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA.,Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA.,Department of Research & Development Center, John D. Dingell VA Medical Center, Detroit, MI, USA
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24
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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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25
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McDonald MW, Dykes A, Jeffers MS, Carter A, Nevins R, Ripley A, Silasi G, Corbett D. Remote Ischemic Conditioning and Stroke Recovery. Neurorehabil Neural Repair 2021; 35:545-549. [PMID: 33955298 PMCID: PMC8135236 DOI: 10.1177/15459683211011224] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Remote ischemic conditioning (RIC) is a noninvasive procedure whereby several periods of ischemia are induced in a limb. Although there is growing interest in using RIC to improve stroke recovery, preclinical RIC research has focused exclusively on neuroprotection, using male animals and the intraluminal suture stroke model, and delivered RIC at times not relevant to either brain repair or behavioral recovery. In alignment with the Stroke Recovery and Rehabilitation Roundtable, we address these shortcomings. First, a standardized session (5-minute inflation/deflation, 4 repetitions) of RIC was delivered using a cuff on the contralesional hindlimb in both male and female Sprague-Dawley rats. Using the endothelin-1 stroke model, RIC was delivered once either prestroke (18 hours before, pre-RIC) or poststroke (4 hours after, post-RIC), and infarct volume was assessed at 24 hours poststroke using magnetic resonance imaging. RIC was delivered at these times to mimic the day before a surgery where clots are possible or as a treatment similar to tissue plasminogen activator, respectively. Pre-RIC reduced infarct volume by 41% compared with 29% with post-RIC. RIC was neuroprotective in both sexes, but males had a 46% reduction of infarct volume compared with 23% in females. After confirming the acute efficacy of RIC, we applied it chronically for 4 weeks, beginning 5 days poststroke. This delayed RIC failed to enhance poststroke behavioral recovery. Based on these findings, the most promising application of RIC is during the hyperacute and early acute phases of stroke, a time when other interventions such as exercise may be contraindicated.
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Affiliation(s)
- Matthew W McDonald
- University of Ottawa, ON, Canada.,Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
| | - Angela Dykes
- University of Ottawa, ON, Canada.,Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
| | - Matthew S Jeffers
- University of Ottawa, ON, Canada.,Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
| | - Anthony Carter
- Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
| | | | | | - Gergely Silasi
- University of Ottawa, ON, Canada.,Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
| | - Dale Corbett
- University of Ottawa, ON, Canada.,Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
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26
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Baig S, Moyle B, Nair KPS, Redgrave J, Majid A, Ali A. Remote ischaemic conditioning for stroke: unanswered questions and future directions. Stroke Vasc Neurol 2021; 6:298-309. [PMID: 33903181 PMCID: PMC8258051 DOI: 10.1136/svn-2020-000722] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/13/2021] [Accepted: 01/31/2021] [Indexed: 11/07/2022] Open
Abstract
Remote ischaemic conditioning (RIC) refers to a process whereby periods of intermittent ischaemia, typically via the cyclical application of a blood pressure cuff to a limb at above systolic pressure, confers systemic protection against ischaemia in spatially distinct vascular territories. The mechanisms underlying this have not been characterised fully but have been shown to involve neural, hormonal and systemic inflammatory signalling cascades. Preclinical and early clinical studies have been promising and suggest beneficial effects of RIC in acute ischaemic stroke, symptomatic intracranial stenosis and vascular cognitive impairment. Through systematic searches of several clinical trials databases we identified 48 active clinical trials of RIC in ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage. We summarise the different RIC protocols and outcome measures studied in ongoing clinical trials and highlight which studies are most likely to elucidate the underlying biological mechanisms of RIC and characterise its efficacy in the near future. We discuss the uncertainties of RIC including the optimal frequency and duration of therapy, target patient groups, cost-effectiveness, the confounding impact of medications and the absence of a clinically meaningful biomarker of the conditioning response. With several large clinical trials of RIC expected to report their outcomes within the next 2 years, this review aims to highlight the most important studies and unanswered questions that will need to be addressed before this potentially widely accessible and low-cost intervention can be used in clinical practice.
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Affiliation(s)
- Sheharyar Baig
- Cerebrovascular Medicine, The University of Sheffield Institute for Translational Neuroscience, Sheffield, UK
| | - Bethany Moyle
- Cerebrovascular Medicine, The University of Sheffield Institute for Translational Neuroscience, Sheffield, UK
| | | | - Jessica Redgrave
- Cerebrovascular Medicine, The University of Sheffield Institute for Translational Neuroscience, Sheffield, UK
| | - Arshad Majid
- Faculty of Medicine and Dentistry, University of Sheffield, Sheffield, UK
| | - Ali Ali
- Geriatrics and Stroke Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK .,Sheffield NIHR Biomedical Research Centre, The University of Sheffield, Sheffield, UK
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27
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Wang Q, Wills M, Han Z, Geng X, Ding Y. Mini Review (Part I): An Experimental Concept on Exercise and Ischemic Conditioning in Stroke Rehabilitation. Brain Circ 2021; 6:242-247. [PMID: 33506146 PMCID: PMC7821806 DOI: 10.4103/bc.bc_63_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/11/2022] Open
Abstract
Stroke remains a leading cause of adult death and disability. Poststroke rehabilitation is vital for reducing the long-term sequelae of brain ischemia. Recently, physical exercise training has been well established as an effective rehabilitation tool, but its efficacy depends on exercise parameters and the patient's capacities, which are often altered following a major cerebrovascular event. Thus, ischemic conditioning as a rehabilitation intervention was considered an “exercise equivalent,” but the investigation is still in its relative infancy. In this mini-review, we discuss the potential for physical exercise or ischemic conditioning and its relation to angiogenesis, neurogenesis, and plasticity in stroke rehabilitation. This allows the readers to understand the context of the research and the application of ischemic conditioning in poststroke rehabilitation.
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Affiliation(s)
- Qingzhu Wang
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Melissa Wills
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Zhenzhen Han
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA.,Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Research and Development Center, John D. Dingell VA Medical Center, Detroit, Michigan, USA
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28
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Lv B, Zhang X, Yuan J, Chen Y, Ding H, Cao X, Huang A. Biomaterial-supported MSC transplantation enhances cell-cell communication for spinal cord injury. Stem Cell Res Ther 2021; 12:36. [PMID: 33413653 PMCID: PMC7791771 DOI: 10.1186/s13287-020-02090-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 12/09/2020] [Indexed: 12/14/2022] Open
Abstract
The spinal cord is part of the central nervous system (CNS) and serves to connect the brain to the peripheral nervous system and peripheral tissues. The cell types that primarily comprise the spinal cord are neurons and several categories of glia, including astrocytes, oligodendrocytes, and microglia. Ependymal cells and small populations of endogenous stem cells, such as oligodendrocyte progenitor cells, also reside in the spinal cord. Neurons are interconnected in circuits; those that process cutaneous sensory input are mainly located in the dorsal spinal cord, while those involved in proprioception and motor control are predominately located in the ventral spinal cord. Due to the importance of the spinal cord, neurodegenerative disorders and traumatic injuries affecting the spinal cord will lead to motor deficits and loss of sensory inputs. Spinal cord injury (SCI), resulting in paraplegia and tetraplegia as a result of deleterious interconnected mechanisms encompassed by the primary and secondary injury, represents a heterogeneously behavioral and cognitive deficit that remains incurable. Following SCI, various barriers containing the neuroinflammation, neural tissue defect (neurons, microglia, astrocytes, and oligodendrocytes), cavity formation, loss of neuronal circuitry, and function must be overcame. Notably, the pro-inflammatory and anti-inflammatory effects of cell–cell communication networks play critical roles in homeostatic, driving the pathophysiologic and consequent cognitive outcomes. In the spinal cord, astrocytes, oligodendrocytes, and microglia are involved in not only development but also pathology. Glial cells play dual roles (negative vs. positive effects) in these processes. After SCI, detrimental effects usually dominate and significantly retard functional recovery, and curbing these effects is critical for promoting neurological improvement. Indeed, residential innate immune cells (microglia and astrocytes) and infiltrating leukocytes (macrophages and neutrophils), activated by SCI, give rise to full-blown inflammatory cascades. These inflammatory cells release neurotoxins (proinflammatory cytokines and chemokines, free radicals, excitotoxic amino acids, nitric oxide (NO)), all of which partake in axonal and neuronal deficit. Given the various multifaceted obstacles in SCI treatment, a combinatorial therapy of cell transplantation and biomaterial implantation may be addressed in detail here. For the sake of preserving damaged tissue integrity and providing physical support and trophic supply for axon regeneration, MSC transplantation has come to the front stage in therapy for SCI with the constant progress of stem cell engineering. MSC transplantation promotes scaffold integration and regenerative growth potential. Integrating into the implanted scaffold, MSCs influence implant integration by improving the healing process. Conversely, biomaterial scaffolds offer MSCs with a sheltered microenvironment from the surrounding pathological changes, in addition to bridging connection spinal cord stump and offering physical and directional support for axonal regeneration. Besides, Biomaterial scaffolds mimic the extracellular matrix to suppress immune responses. Here, we review the advances in combinatorial biomaterial scaffolds and MSC transplantation approach that targets certain aspects of various intercellular communications in the pathologic process following SCI. Finally, the challenges of biomaterial-supported MSC transplantation and its future direction for neuronal regeneration will be presented.
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Affiliation(s)
- Bin Lv
- Department of Orthopedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, 212002, Jiangsu Province, China
| | - Xing Zhang
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, 52074, Aachen, Germany
| | - Jishan Yuan
- Department of Orthopedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, 212002, Jiangsu Province, China
| | - Yongxin Chen
- Department of Orthopedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, 212002, Jiangsu Province, China
| | - Hua Ding
- Department of Orthopedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, 212002, Jiangsu Province, China
| | - Xinbing Cao
- Department of Orthopedics, The Affiliated Hospital of Jiangsu University, Zhenjiang, 212000, Jiangsu Province, China.
| | - Anquan Huang
- Department of Orthopedics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215000, Jiangsu Province, China.
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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: 14] [Impact Index Per Article: 4.7] [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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Paul S, Candelario-Jalil E. Emerging neuroprotective strategies for the treatment of ischemic stroke: An overview of clinical and preclinical studies. Exp Neurol 2020; 335:113518. [PMID: 33144066 DOI: 10.1016/j.expneurol.2020.113518] [Citation(s) in RCA: 283] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 12/12/2022]
Abstract
Stroke is the leading cause of disability and thesecond leading cause of death worldwide. With the global population aged 65 and over growing faster than all other age groups, the incidence of stroke is also increasing. In addition, there is a shift in the overall stroke burden towards younger age groups, particularly in low and middle-income countries. Stroke in most cases is caused due to an abrupt blockage of an artery (ischemic stroke), but in some instances stroke may be caused due to bleeding into brain tissue when a blood vessel ruptures (hemorrhagic stroke). Although treatment options for stroke are still limited, with the advancement in recanalization therapy using both pharmacological and mechanical thrombolysis some progress has been made in helping patients recover from ischemic stroke. However, there is still a substantial need for the development of therapeutic agents for neuroprotection in acute ischemic stroke to protect the brain from damage prior to and during recanalization, extend the therapeutic time window for intervention and further improve functional outcome. The current review has assessed the past challenges in developing neuroprotective strategies, evaluated the recent advances in clinical trials, discussed the recent initiative by the National Institute of Neurological Disorders and Stroke in USA for the search of novel neuroprotectants (Stroke Preclinical Assessment Network, SPAN) and identified emerging neuroprotectants being currently evaluated in preclinical studies. The underlying molecular mechanism of each of the neuroprotective strategies have also been summarized, which could assist in the development of future strategies for combinational therapy in stroke treatment.
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Affiliation(s)
- Surojit Paul
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA.
| | - Eduardo Candelario-Jalil
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
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31
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An JQ, Cheng YW, Guo YC, Wei M, Gong MJ, Tang YL, Yuan XY, Song WF, Mu CY, Zhang AF, Saguner AM, Li GL, Luo GG. Safety and efficacy of remote ischemic postconditioning after thrombolysis in patients with stroke. Neurology 2020; 95:e3355-e3363. [PMID: 33028663 DOI: 10.1212/wnl.0000000000010884] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/12/2020] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To determine the effect of remote ischemic postconditioning (RIPC) on patients with acute ischemic stroke (AIS) undergoing IV thrombolysis (IVT). METHODS A single-center randomized controlled trial was performed with patients with AIS receiving IVT. Patients in the RIPC group were administered RIPC treatment (after IVT) during hospitalization. The primary endpoint was a score of 0 or 1 on the modified Rankin scale (mRS) at day 90. The safety, tolerability, and neuroprotection biomarkers associated with RIPC were also evaluated. RESULTS We collected data from both the RIPC group (n = 34) and the control group (n = 34). The average duration of hospitalization was 11.2 days. There was no significant difference between 2 groups at admission for the NIH Stroke Scale score (p = 0.364) or occur-to-treatment time (p = 0.889). Favorable recovery (mRS score 0-1) at 3 months was obtained in 71.9% of patients in the RIPC group vs 50.0% in the control group (adjusted odds ratio 9.85, 95% confidence interval 1.54-63.16; p = 0.016). We further found significantly lower plasma S100-β (p = 0.007) and higher vascular endothelial growth factor (p = 0.003) levels in the RIPC group than in the control group. CONCLUSIONS Repeated RIPC combined with IVT can significantly facilitate recovery of nerve function and improve clinical prognosis of patients with AIS. CLINICALTRIALSGOV IDENTIFIER NCT03218293. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that RIPC after tissue plasminogen activator treatment of AIS significantly increases the proportion of patients with an MRS score of 0 or 1 at 90 days.
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Affiliation(s)
- Jia-Qi An
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland.
| | - Ya-Wen Cheng
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland
| | - Yi-Chen Guo
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland.
| | - Meng Wei
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland
| | - Min-Jie Gong
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland
| | - Yong-Lan Tang
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland
| | - Xing-Yun Yuan
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland
| | - Wen-Feng Song
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland
| | - Chun-Ying Mu
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland
| | - Ai-Feng Zhang
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland
| | - Ardan M Saguner
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland
| | - Guo-Liang Li
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland.
| | - Guo-Gang Luo
- From the Stroke Centre and Department of Neurology (J.-q.A., Y.-w.C., Y.-c.G., M.W., M.-j.G., Y.-l.T., X.-y.Y., W.-f. S., C.-y.M., G.-g.L.) and Atrial Fibrillation Centre and Department of Cardiovascular Medicine (J.-q.A., G.-l L.), First Affiliated Hospital of Xi'an Jiaotong University, China; Renal Division (A.-f.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and Department of Cardiology (A.M.S.), University Heart Center Zurich, Switzerland.
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Wills M, Ding Y. Beyond reperfusion: Enhancing endogenous restorative functions after an ischemic stroke. Brain Circ 2020; 6:223-224. [PMID: 33506144 PMCID: PMC7821811 DOI: 10.4103/bc.bc_72_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 01/14/2023] Open
Affiliation(s)
- Melissa Wills
- Department of Neurosurgery, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, School of Medicine, Wayne State University, Detroit, MI, USA
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33
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Samandari H, Nabavizadeh F, Ashabi G. Age-related difference in protective effect of early post-conditioning on ischemic brain injury: possible involvement of MAP-2/Synaptophysin role. Metab Brain Dis 2019; 34:1771-1780. [PMID: 31471737 DOI: 10.1007/s11011-019-00484-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 08/15/2019] [Indexed: 12/16/2022]
Abstract
Brain Ischemia/Reperfusion (I/R) injury leads to the failure of the microtubules function and neuronal death. Ischemic post-conditioning is defined as a series of rapid alternating interruptions of blood flow in the first seconds of reperfusion. In the present study, the caspase-3, Microtubule-Associated Protein-2 (MAP-2), Protein Kinase C α (PKCα), c-fos, and synaptophysin were evaluated in the hippocampus of focal I/R post-conditioning model in a time -dependent study in aged and young rats. Adult and aged rats were subjected to right MCAO for 30 min and post-conditioned (10 s) for 3 cycles. Sensory-motor tests were performed, and locomotion and anxiety-like behavior were evaluated. Molecular tests were done by detection kit, RT-PCR, and Western blotting techniques. Ninety-six hours after I/R post-conditioning, neurological signs, locomotion, anxiety-like behavior, and ischemic area were improved in young rats compared to 6 h after I/R post-conditioning (P < 0.001). Caspase-3 activity declined in the hippocampus and cortex of I/R post-conditioned young rats in 96 h after I/R post-conditioning compared with 6 h after I/R post-conditioning (P < 0.001). Also, MAP-2 mRNA, MAP-2 protein level, PKCα, c-fos and synaptophysin protein levels were enhanced during post-conditioning in young rats in 96 h after I/R post-conditioning compared with 6 h after induction of I/R post-conditioning. The results of the present study suggested that, early post-conditioning might be considered as a candidate for therapeutic methods against I/R in the adult animals not aged rats. Moreover, inhibition of cell death in post-conditioned ischemic rats was found to be regulated by some neuroprotective molecules as well as MAP-2 and c-fos in young rats. Graphical abstract Graphical abstract representing the post-conditioning (PC) treatment timeline in adult and old rats.
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Affiliation(s)
- Hedayat Samandari
- Electrophysiology Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Physiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Nabavizadeh
- Department of Physiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghorbangol Ashabi
- Department of Physiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Malone K, Amu S, Moore AC, Waeber C. Immunomodulatory Therapeutic Strategies in Stroke. Front Pharmacol 2019; 10:630. [PMID: 31281252 PMCID: PMC6595144 DOI: 10.3389/fphar.2019.00630] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/16/2019] [Indexed: 12/14/2022] Open
Abstract
The role of immunity in all stages of stroke is increasingly being recognized, from the pathogenesis of risk factors to tissue repair, leading to the investigation of a range of immunomodulatory therapies. In the acute phase of stroke, proposed therapies include drugs targeting pro-inflammatory cytokines, matrix metalloproteinases, and leukocyte infiltration, with a key objective to reduce initial brain cell toxicity. Systemically, the early stages of stroke are also characterized by stroke-induced immunosuppression, where downregulation of host defences predisposes patients to infection. Therefore, strategies to modulate innate immunity post-stroke have garnered greater attention. A complementary objective is to reduce longer-term sequelae by focusing on adaptive immunity. Following stroke onset, the integrity of the blood–brain barrier is compromised, exposing central nervous system (CNS) antigens to systemic adaptive immune recognition, potentially inducing autoimmunity. Some pre-clinical efforts have been made to tolerize the immune system to CNS antigens pre-stroke. Separately, immune cell populations that exhibit a regulatory phenotype (T- and B- regulatory cells) have been shown to ameliorate post-stroke inflammation and contribute to tissue repair. Cell-based therapies, established in oncology and transplantation, could become a strategy to treat the acute and chronic stages of stroke. Furthermore, a role for the gut microbiota in ischaemic injury has received attention. Finally, the immune system may play a role in remote ischaemic preconditioning-mediated neuroprotection against stroke. The development of stroke therapies involving organs distant to the infarct site, therefore, should not be overlooked. This review will discuss the immune mechanisms of various therapeutic strategies, surveying published data and discussing more theoretical mechanisms of action that have yet to be exploited.
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Affiliation(s)
- Kyle Malone
- Department of Pharmacology and Therapeutics, School of Pharmacy, University College Cork, Cork, Ireland
| | - Sylvie Amu
- Cancer Research @UCC, University College Cork, Cork, Ireland
| | - Anne C Moore
- School of Biochemistry and Cell Biology, University College Cork, Cork, Ireland
| | - Christian Waeber
- Department of Pharmacology and Therapeutics, School of Pharmacy, University College Cork, Cork, Ireland
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35
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Landman TRJ, Schoon Y, Warlé MC, de Leeuw FE, Thijssen DHJ. Remote Ischemic Conditioning as an Additional Treatment for Acute Ischemic Stroke. Stroke 2019; 50:1934-1939. [PMID: 31154944 DOI: 10.1161/strokeaha.119.025494] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Thijs R J Landman
- From the Department of Physiology (T.R.J.L., D.H.J.T.), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, Gelderland, the Netherlands
| | - Yvonne Schoon
- Department of Geriatric Medicine (Y.S.), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, Gelderland, the Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Gelderland, the Netherlands (M.C.W.)
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Cognitive Neuroscience, Nijmegen, Gelderland, the Netherlands (F.-E.d.L.)
| | - Dick H J Thijssen
- From the Department of Physiology (T.R.J.L., D.H.J.T.), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, Gelderland, the Netherlands
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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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Yang J, Shakil F, Cho S. Peripheral Mechanisms of Remote Ischemic Conditioning. CONDITIONING MEDICINE 2019; 2:61-68. [PMID: 32313875 PMCID: PMC7169943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Ischemic conditioning induces an endogenous protective mechanism that allows organisms to develop resistance to subsequent insults. The conditioning effect occurs across organs and species. Recently, much attention has been given to remote ischemic limb conditioning due to its non-invasive nature and potential therapeutic applications. While tolerance is induced at the primary injury site (e.g. the heart in cardiac ischemia and the brain in stroke), the site of conditioning application is away from the target organ, suggesting the protective factors are extrinsic in nature rather than intrinsic. This review will focus on the peripheral factors that account for the induction of tolerance. Topics of particular interest are blood flow changes, peripheral neural pathways, humoral factors in circulation, and the peripheral immune system. This review will also discuss how conditioning may negatively affect metabolically compromised conditions, its optimal dose, and window for therapy development.
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Affiliation(s)
- Jiwon Yang
- Burke Neurological Institute, White Plains, NY 10605
- The Jackson Laboratory, Sacramento, CA 95838
| | | | - Sunghee Cho
- Burke Neurological Institute, White Plains, NY 10605
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10065
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