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Kakarla R, Vinjavarapu LA, Krishnamurthy S. Diet and Nutraceuticals for treatment and prevention of primary and secondary stroke: Emphasis on nutritional antiplatelet and antithrombotic agents. Neurochem Int 2024; 179:105823. [PMID: 39084351 DOI: 10.1016/j.neuint.2024.105823] [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: 04/12/2024] [Revised: 07/26/2024] [Accepted: 07/29/2024] [Indexed: 08/02/2024]
Abstract
Ischemic stroke is a devastating disease that causes morbidity and mortality. Malnutrition following ischemic stroke is common in stroke patients. During the rehabilitation, the death rates of stroke patients are significantly increased due to malnutrition. Nutritional supplements such as protein, vitamins, fish, fish oils, moderate wine or alcohol consumption, nuts, minerals, herbal products, food colorants, marine products, fiber, probiotics and Mediterranean diets have improved neurological functions in stroke patients as well as their quality of life. Platelets and their mediators contribute to the development of clots leading to stroke. Ischemic stroke patients are treated with thrombolytics, antiplatelets, and antithrombotic agents. Several systematic reviews, meta-analyses, and clinical trials recommended that consumption of these nutrients and diets mitigated the vascular, peripheral, and central complications associated with ischemic stroke (Fig. 2). Particularly, these nutraceuticals mitigated the platelet adhesion, activation, and aggregation that intended to reduce the risks of primary and secondary stroke. Although these nutraceuticals mitigate platelet dysfunction, there is a greater risk of bleeding if consumed excessively. Moreover, malnutrition must be evaluated and adequate amounts of nutrients must be provided to stroke patients during intensive care units and rehabilitation periods. In this review, we have summarized the importance of diet and nutraceuticals in ameliorating neurological complications and platelet dysfunction with an emphasis on primary and secondary prevention of ischemic stroke.
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Affiliation(s)
- Ramakrishna Kakarla
- KL College of Pharmacy, Koneru Lakshmaiah Education Foundation, Vaddeswaram, Guntur, 522302, India
| | | | - Sairam Krishnamurthy
- Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology, Banaras Hindu University (IIT BHU), Varanasi, Uttar Pradesh, India.
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Shiraishi R, Shiraishi N, Fujimoto Y, Ogawa T. Malnutrition suppresses improvements in depression symptoms in older adult patients with stroke undergoing convalescent rehabilitation. Clin Nutr ESPEN 2024; 63:508-514. [PMID: 39053700 DOI: 10.1016/j.clnesp.2024.07.013] [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: 04/06/2024] [Revised: 06/22/2024] [Accepted: 07/04/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND & AIMS Depression symptoms are both prevalent and associated with poor prognosis in patients with convalescent stroke. Therefore, the improvement of depression symptoms is important for patients with convalescent stroke. This study aimed to examine whether malnutrition diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria and its components are associated with improvements in depression symptoms in patients with stroke undergoing rehabilitation. METHODS This was a retrospective cohort study of older adult patients with convalescent stroke. Inclusion criteria comprised patients aged ≥65 years experiencing their first occurrence of stroke and admitted for rehabilitation therapy. Patients were classified into either the malnutrition or normal nutrition groups based on the diagnosis of malnutrition using the GLIM criteria. The Geriatric Depression Screening Scale (GDS)-15 was used to evaluate depression symptoms. The primary outcome of the study was the change in depression symptoms, indicating a change in GDS score from admission to discharge. The association between malnutrition diagnosed using the GLIM criteria and change in depression symptoms was assessed using multiple regression analysis. Additionally, associations with the constructs of the GLIM criteria were investigated. RESULTS The malnutrition group comprised 64 (45%) patients, with a mean age of 78.2 years; 77 (54%) and 66 (46%) were males and females, respectively. Multiple regression analysis showed that malnutrition, diagnosed using the GLIM criteria (β: -0.306, p < 0.001), was independently associated with changes in depression symptoms. Moreover, the GLIM criterion component of reduced muscle mass (β: -0.235, p < 0.001) demonstrated a negative association with a change in depression symptoms. CONCLUSION Malnutrition and reduced muscle mass, diagnosed using the GLIM criteria in patients with stroke undergoing convalescent rehabilitation, were found to suppress the improvement of depression symptoms.
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Affiliation(s)
- Ryo Shiraishi
- Clinical Education and Research Center, Chuzan Hospital, 6-2-1 Matsumoto, Okinawa City, Okinawa 904-2151, Japan; Department of Clinical Research and Quality Management, Graduate School of Medicine, University of the Ryukyus, Nishihara-cho, Okinawa 903-0215, Japan; Department of Rehabilitation Medicine, Aichi Medical University, Nagakute City, Aichi 480-1103, Japan.
| | - Nami Shiraishi
- Clinical Education and Research Center, Chuzan Hospital, 6-2-1 Matsumoto, Okinawa City, Okinawa 904-2151, Japan.
| | - Yuta Fujimoto
- Clinical Education and Research Center, Chuzan Hospital, 6-2-1 Matsumoto, Okinawa City, Okinawa 904-2151, Japan.
| | - Takahiro Ogawa
- Clinical Education and Research Center, Chuzan Hospital, 6-2-1 Matsumoto, Okinawa City, Okinawa 904-2151, Japan; Department of Rehabilitation Medicine, Aichi Medical University, Nagakute City, Aichi 480-1103, Japan.
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Wang XP, Yan D, Jin XP, Zhang WY, Shi T, Wang X, Song W, Xiong X, Guo D, Chen S. The role of amino acid metabolism alterations in acute ischemic stroke: From mechanism to application. Pharmacol Res 2024; 207:107313. [PMID: 39025169 DOI: 10.1016/j.phrs.2024.107313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/10/2024] [Accepted: 07/15/2024] [Indexed: 07/20/2024]
Abstract
Acute ischemic stroke (AIS) is the most prevalent type of stroke, and due to its high incidence, disability rate, and mortality rate, it imposes a significant burden on the health care system. Amino acids constitute one of the most crucial metabolic products within the human body, and alterations in their metabolic pathways have been identified in the microenvironment of AIS, thereby influencing the pathogenesis, severity, and prognosis of AIS. The amino acid metabolism characteristics in AIS are complex. On one hand, the dynamic progression of AIS continuously reshapes the amino acid metabolism pattern. Conversely, changes in the amino acid metabolism pattern also exert a double-edged effect on AIS. This interaction is bidirectional, dynamic, heterogeneous, and dose-specific. Therefore, the distinctive metabolic reprogramming features surrounding amino acids during the AIS process are systematically summarized in this paper, aiming to provide potential investigative strategies for the early diagnosis, treatment approaches, and prognostic enhancement of AIS.
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Affiliation(s)
- Xiang-Ping Wang
- First People's Hospital of Linping District; Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 311100, China.
| | - Dan Yan
- Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou 311202, China.
| | - Xia-Ping Jin
- First People's Hospital of Linping District; Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 311100, China.
| | - Wen-Yan Zhang
- First People's Hospital of Linping District; Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 311100, China.
| | - Tao Shi
- First People's Hospital of Linping District; Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 311100, China.
| | - Xiang Wang
- First People's Hospital of Linping District; Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 311100, China.
| | - Wenjuan Song
- First People's Hospital of Linping District; Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 311100, China.
| | - Xing Xiong
- Traditional Chinese Medical Hospital of Xiaoshan,The Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 311200, Zhejiang Province, China.
| | - Duancheng Guo
- Cancer Institute, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.
| | - Sheng Chen
- First People's Hospital of Xiaoshan District,Hangzhou 311200, Zhejiang Province, China.
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Gao Z, Chen H. Advances in the beneficial effects of nutrition on stroke-related Sarcopenia: A narrative review. Medicine (Baltimore) 2023; 102:e34048. [PMID: 37327307 PMCID: PMC10270533 DOI: 10.1097/md.0000000000034048] [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: 04/05/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023] Open
Abstract
Stroke is one of the most common causes of disability in adults. Sarcopenia is a syndrome characterized by progressive systemic muscle loss and functional decline. The decrease in skeletal muscle mass and muscle function throughout the body after stroke cannot be explained by neurological motor disorders due to brain injury alone, it is considered to be a secondary sarcopenia known as stroke-related sarcopenia. Mounting evidences showed that stroke-related sarcopenia might promote the occurrence and development of sarcopenia through various pathogenesis such as muscle atrophy, dysphagia, inflammation, and malnutrition, etc. At present, the main indicators used to assess malnutrition in patients with stroke-related sarcopenia include temporalis muscle thickness, calf circumference, phase angle, geriatric nutritional risk index and mini-nutritional assessment short-form, etc. Currently, there is no particularly effective method to curb its progression, but supplementation with essential amino acids, whey protein combined with vitamin D, high energy diet, avoiding Polypharmacy, as well as increasing physical activity level and reducing sedentary lifestyle may improve the malnutrition status of stroke patients, and increase the muscle mass and skeletal muscle index, further delay or even prevent the development of stroke-related sarcopenia. This article reviews the latest research progress on the characteristics, epidemiology, pathogenesis and the role of nutrition in stroke-related sarcopenia, so as to provide reference for the clinical treatment and rehabilitation of stroke-related sarcopenia.
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Affiliation(s)
- Zhiqiang Gao
- School of Public Health, Hubei University of Medicine, Shiyan, China
| | - Hongxia Chen
- Institute of Biomedical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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Mellen RH, Girotto OS, Marques EB, Laurindo LF, Grippa PC, Mendes CG, Garcia LNH, Bechara MD, Barbalho SM, Sinatora RV, Haber JFDS, Flato UAP, Bueno PCDS, Detregiachi CRP, Quesada K. Insights into Pathogenesis, Nutritional and Drug Approach in Sarcopenia: A Systematic Review. Biomedicines 2023; 11:biomedicines11010136. [PMID: 36672642 PMCID: PMC9856128 DOI: 10.3390/biomedicines11010136] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Sarcopenia is a multifactorial condition related to the loss of muscle mass and strength due to aging, eating habits, physical inactivity, or even caused by another disease. Affected individuals have a higher risk of falls and may be associated with heart disease, respiratory diseases, cognitive impairment, and consequently an increased risk of hospitalization, in addition to causing an economic impact due to the high cost of care during the stay in hospitals. The standardization of appropriate treatment for patients with sarcopenia that could help reduce pathology-related morbidity is necessary. For these reasons, this study aimed to perform a systematic review of the role of nutrition and drugs that could ameliorate the health and quality of life of sarcopenic patients and PRISMA guidelines were followed. Lifestyle interventions have shown a profound impact on sarcopenia treatment but using supplements and different drugs can also impact skeletal muscle maintenance. Creatine, leucine, branched-chain amino acids, omega 3, and vitamin D can show benefits. Although with controversial results, medications such as Metformin, GLP-1, losartan, statin, growth hormone, and dipeptidyl peptidase 4 inhibitors have also been considered and can alter the sarcopenic's metabolic parameters, protect against cardiovascular diseases and outcomes, while protecting muscles.
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Affiliation(s)
- Rodrigo Haber Mellen
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Otávio Simões Girotto
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Eduarda Boni Marques
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Lucas Fornari Laurindo
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Paulo Cesar Grippa
- Postgraduate Program in Structural and Functional Interactions in Rehabilitation—University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Claudemir Gregório Mendes
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
- Postgraduate Program in Structural and Functional Interactions in Rehabilitation—University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Lorena Natalino Haber Garcia
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Marcelo Dib Bechara
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
- Postgraduate Program in Structural and Functional Interactions in Rehabilitation—University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Sandra Maria Barbalho
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
- Postgraduate Program in Structural and Functional Interactions in Rehabilitation—University of Marília (UNIMAR), São Paulo 17525-902, Brazil
- School of Food and Technology of Marilia (FATEC), São Paulo 17590-000, Brazil
- Correspondence: ; Tel.: 55-14-99655-3190
| | - Renata Vargas Sinatora
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | | | - Uri Adrian P. Flato
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Patricia Cincotto dos Santos Bueno
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
- Department of Animal Sciences, School of Veterinary Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Claudia Rucco Penteado Detregiachi
- Postgraduate Program in Structural and Functional Interactions in Rehabilitation—University of Marília (UNIMAR), São Paulo 17525-902, Brazil
| | - Karina Quesada
- Department of Biochemistry and Pharmacology, School of Medicine, University of Marília (UNIMAR), São Paulo 17525-902, Brazil
- School of Food and Technology of Marilia (FATEC), São Paulo 17590-000, Brazil
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Zhang XM, Jiao J, Xu T, Wu XJ. The association between frailty of older stroke patients during hospitalization and one-year all-cause mortality: A multicenter survey in China. Int J Nurs Sci 2022; 9:162-168. [PMID: 35509704 PMCID: PMC9052266 DOI: 10.1016/j.ijnss.2022.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 02/04/2022] [Accepted: 02/16/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Frailty is a common geriatric syndrome defined as multiple deficits, impairing the capacity to figure out insult. Previous studies have reported a significant association between frailty and mortality in stroke patients. This study aimed to explore the association between frailty and mortality among older Chinese stroke patients. Methods This study was a secondary analysis of a multicenter prospective cohort study conducted in older Chinese inpatients from October 2018 to February 2020, and patients with a primary diagnosis of stroke including hemorrhage and ischemia, were included in our study. Frailty of older inpatients with stroke from six hospitals was measured by the FRAIL scale, and a one-year follow-up was performed by well-trained nurses of these hospitals via telephone. Multivariable logistic regression was used to detect the association between frailty and one-year mortality. Results A total of 530 stroke patients with an average age of 72.94 (SD = 5.79) years were included in the present study. There were 37 (7.0%) hemorrhagic strokes and 493 (93.0%) ischemic strokes, with 228 (43.0%) females in this population. The prevalence of frailty was 22.5%. In the logistic regression model with adjustment for age, sex, instrumental activities of daily living (IADL), basic activities of daily living (ADL), education, history of falls, BMI, smoking, alcohol consumption, low handgrip strength, type of stroke and polypharmacy, stroke patients with frailty had an increased risk of one-year mortality compared to those without frailty (OR = 3.38, 95% CI: 1.22–9.37, P = 0.019). Conclusion Our study indicated that frailty was an independent risk factor for one-year all-cause mortality among older stroke patients in China. Frailty may be an essential factor for clinicians to consider before making a comprehensive treatment, and corresponding mixed interventions, including exercise training and nutritional programs, need to be conducted among older stroke patients.
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Zhang Y, Chen Z, Sun P, Xu Q, Chen N. Effect of low-level ultrasound treatment on the production of L-leucine by Corynebacterium glutamicum in fed-batch culture. Bioengineered 2021; 12:1078-1090. [PMID: 33775210 PMCID: PMC8806274 DOI: 10.1080/21655979.2021.1906028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/09/2021] [Accepted: 03/09/2021] [Indexed: 11/29/2022] Open
Abstract
Various process intensification methods were proposed to improve the yield, quality, and safety of fermented products. Here, we report the enhancement of L-leucine production by Corynebacterium glutamicum CP using ultrasound-assisted fed-batch fermentation. Response surface methodology was employed to optimize the sonication conditions. At an ultrasonic power density of 94 W/L, frequency of 25 kHz, interval of 31 min, and duration of 37 s, C. glutamicum CP produced 52.89 g/L of L-leucine in 44 h, representing a 21.6% increase compared with the control. The production performance of L-leucine was also improved under ultrasonic treatment. Moreover, the effects of ultrasound treatment on the fermentation performance of L-leucine were studied in terms of cell morphology, cell membrane permeability, and enzyme activity. The results indicate that ultrasonication is an efficient method for the intensification of L-leucine production by C. glutamicum CP.
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Affiliation(s)
- Yufu Zhang
- National and Local United Engineering Lab of Metabolic Control Fermentation Technology, Tianjin University of Science & Technology, Tianjin, PR China
- College of Biotechnology, Tianjin University of Science & Technology, Tianjin, PR China
| | - Zhichao Chen
- National and Local United Engineering Lab of Metabolic Control Fermentation Technology, Tianjin University of Science & Technology, Tianjin, PR China
- College of Biotechnology, Tianjin University of Science & Technology, Tianjin, PR China
| | - Pengjie Sun
- National and Local United Engineering Lab of Metabolic Control Fermentation Technology, Tianjin University of Science & Technology, Tianjin, PR China
- College of Biotechnology, Tianjin University of Science & Technology, Tianjin, PR China
| | - Qingyang Xu
- National and Local United Engineering Lab of Metabolic Control Fermentation Technology, Tianjin University of Science & Technology, Tianjin, PR China
- College of Biotechnology, Tianjin University of Science & Technology, Tianjin, PR China
| | - Ning Chen
- National and Local United Engineering Lab of Metabolic Control Fermentation Technology, Tianjin University of Science & Technology, Tianjin, PR China
- College of Biotechnology, Tianjin University of Science & Technology, Tianjin, PR China
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Nutritional Supplements and Neuroprotective Diets and Their Potential Clinical Significance in Post-Stroke Rehabilitation. Nutrients 2021; 13:nu13082704. [PMID: 34444864 PMCID: PMC8399756 DOI: 10.3390/nu13082704] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 12/23/2022] Open
Abstract
Nutrition and rehabilitation are crucial in post-stroke recovery, especially in the elderly. Since stroke is the leading cause of long-term disability, there is a need to promote special, individually tailored nutrition strategies targeting older patients with low motor ability. Chronic stroke survivors have higher risk of developing nutrition-related chronic diseases, such as sarcopenia, anemia, type 2 diabetes mellitus and osteoporosis. Moreover, reduced motor activity, cognitive impairment and depression might be aggravated by poor malnutrition status. Accumulated data suggest that nutritional supplements and neuroprotective diets can be associated with better effectiveness of post-stroke rehabilitation as well as brain recovery. Therefore, this review focuses on preventive strategies that can improve dietary intake and change dietary patterns. We highlight the importance of neuroprotective diets, the problem of dysphagia and the role of nutrition in rehabilitation. This article focuses on potential nutritional supplements and neuroprotective diets that may have an impact on functional recovery during and after rehabilitation. Moreover, a new approach to post-stroke neuroplasticity including the use of agents from marine sources such as fucoxanthin and tramiprosate as compounds that might be used as potential neuroprotectants with antioxidative and anti-inflammatory properties is introduced.
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Chelluboina B, Vemuganti R. Therapeutic potential of nutraceuticals to protect brain after stroke. Neurochem Int 2020; 142:104908. [PMID: 33220386 DOI: 10.1016/j.neuint.2020.104908] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023]
Abstract
Stroke leads to significant neuronal death and long-term neurological disability due to synergistic pathogenic mechanisms. Stroke induces a change in eating habits and in many cases, leads to undernutrition that aggravates the post-stroke pathology. Proper nutritional regimen remains a major strategy to control the modifiable risk factors for cardiovascular and cerebrovascular diseases including stroke. Studies indicate that nutraceuticals (isolated and concentrated form of high-potency natural bioactive substances present in dietary nutritional components) can act as prophylactic as well as adjuvant therapeutic agents to prevent stroke risk, to promote ischemic tolerance and to reduce post-stroke consequences. Nutraceuticals are also thought to regulate blood pressure, delay neurodegeneration and improve overall vascular health. Nutraceuticals potentially mediate these effects by their powerful antioxidant and anti-inflammatory properties. This review discusses the studies that have highlighted the translational potential of nutraceuticals as stroke therapies.
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Affiliation(s)
- Bharath Chelluboina
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Raghu Vemuganti
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA; William S. Middleton Veterans Administration Hospital, Madison, WI, USA.
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