Stroke neuroprotection revisited: Intra-arterial verapamil is profoundly neuroprotective in experimental acute ischemic stroke

While clinical trials have now solidified the role of thrombectomy in emergent large vessel occlusive stroke, additional therapies are needed to optimize patient outcome. Using our previously described experimental ischemic stroke model for evaluating adjunctive intra-arterial drug therapy after vessel recanalization, we studied the potential neuroprotective effects of verapamil. A calcium channel blocker, verapamil is often infused intra-arterially by neurointerventionalists to treat cerebral vasospasm. Such a direct route of administration allows for both focused targeting of stroke-impacted brain tissue and minimizes potential systemic side effects. Intra-arterial administration of verapamil at a flow rate of 2.5 µl/min and injection volume of 10 µl immediately after middle cerebral artery recanalization in C57/Bl6 mice was shown to be profoundly neuroprotective as compared to intra-arterial vehicle-treated stroke controls. Specifically, we noted a significant (P ≤ 0.05) decrease in infarct volume, astrogliosis, and cellular apoptosis as well as a significant increase in neuronal survival and functional outcome over seven days. Furthermore, intra-arterial administration of verapamil was well tolerated with no hemorrhage, systemic side effects, or increased mortality. Thus, verapamil administered intra-arterially immediately following recanalization in experimental ischemic stroke is both safe and neuroprotective and merits further study as a potential therapeutic adjunct to thrombectomy.     

Augmenting collateral blood flow during ischemic stroke via transient aortic occlusion

Collateral circulation provides an alternative route for blood flow to reach ischemic tissue during a stroke. Blood flow through the cerebral collaterals is a critical predictor of clinical prognosis after stroke and response to recanalization, but data on collateral dynamics and collateral therapeutics are lacking. Here, we investigate the efficacy of a novel approach to collateral blood flow augmentation to increase collateral circulation by optically recording blood flow in leptomeningeal collaterals in a clinically relevant model of ischemic stroke. Using high-resolution laser speckle contrast imaging (LSCI) during thromboembolic middle cerebral artery occlusion (MCAo), we demonstrate that transiently diverting blood flow from peripheral circulation towards the brain via intra-aortic catheter and balloon induces persistent increases in blood flow through anastomoses between the anterior and middle cerebral arteries. Increased collateral flow restores blood flow in the distal middle cerebral artery segments to baseline levels during aortic occlusion and persists for over 1 hour after removal of the aortic balloon. Given the importance of collateral circulation in predicting stroke outcome and response to treatment, and the potential of collateral flow augmentation as an adjuvant or stand-alone therapy for acute ischemic stroke, this data provide support for further development and translation of collateral therapeutics including transient aortic occlusion.     

硫酸镁对脑缺血再灌注大鼠脑组织Bcl-2表达的影响及神经保护作用

目的探讨硫酸镁对脑缺血再灌注大鼠脑组织抗凋亡蛋白Bcl-2表达的影响及脑保护作用。方法将32只大鼠随机分为缺血组(n=15)、硫酸镁组(n=15)和正常对照组(n=2)。采用改良的Pulsinelli法建立脑缺血再灌注大鼠模型;制模后分别给予缺血组和硫酸镁组大鼠腹腔注射生理盐水(1.5 ml/d)及硫酸镁(90 mg/kg.d)。缺血再灌注第1、3、7 d分别观察各组大鼠海马CA1区病理学改变和Bcl-2的表达水平。结果正常对照组大鼠海马CA1区神经细胞数量多,排列整齐。缺血再灌注1 d时,缺血组及硫酸镁组大鼠海马CA1区神经元均未见明显死亡;3 d时,缺血组海马CA1区神经元可见少量死亡,残存神经细胞呈较严重缺血性改变,硫酸镁组海马CA1区神经元无明显死亡;7 d时,缺血组海马CA1区神经元大部分死亡,伴有小胶质细胞增生,硫酸镁组仅见部分神经元死亡。与缺血组相比,硫酸镁组神经元受损程度较轻,坏死区较小。硫酸镁组缺血再灌注各时间点大鼠Bcl-2阳性细胞较缺血组均明显增加(均P<0.05)。结论硫酸镁能上调脑组织Bcl-2的表达,对缺血再灌注大鼠的脑组织有明显的保护作用。     

Bone marrow stromal cells as a therapeutic treatment for ischemic stroke

Cerebral ischemia remains the most frequent cause of death and quality-of-life impairments due to neurological deficits, and accounts for the majority of total healthcare costs. However, treatments for cerebral ischemia are limited. Over the last decade, bone marrow stromal cell (BMSC) therapy has emerged as a particularly appealing option, as it is possible to help patients even when initiated days or even weeks after the ischemic insult. BMSCs are a class of multipotent, self-renewing cells that give rise to differentiated progeny when implanted into appropriate tissues. Therapeutic effects of BMSC treatment for ischemic stroke, including sensory and motor recovery, have been reported in pre-clinical studies and clinical trials. In this article, we review the recent progress in BMSC-based therapy for ischemic stroke, focusing on the route of delivery and pre-processing of BMSCs. Selecting an optimal delivery route is of particular importance. The ideal approach, as well as the least risky, for translational applications still requires further identification. Appropriate preprocessing of BMSCs or combination therapy has the benefit of achieving the maximum possible restoration. Further pre-clinical studies are required to determine the time-window for transplantation and the appropriate dosage of cells.     

Nitric oxide: considerations for the treatment of ischemic stroke

Some 40 years ago it was recognized by Furchgott and colleagues that the endothelium releases a vasodilator, endothelium-derived relaxing factor (EDRF). Later on, several groups identified EDRF to be a gas, nitric oxide (NO). Since then, NO was identified as one of the most versatile and unique molecules in animal and human biology. Nitric oxide mediates a plethora of physiological functions, for example, maintenance of vascular tone and inflammation. Apart from these physiological functions, NO is also involved in the pathophysiology of various disorders, specifically those in which regulation of blood flow and inflammation has a key role. The aim of the current review is to summarize the role of NO in cerebral ischemia, the most common cause of stroke.     

Genistein attenuates brain damage induced by transient cerebral ischemia through up-regulation of Nrf2 expression in ovariectomized rats

Objective: Postmenopausal women possess higher incidence of stroke and worse prognosis. Although estrogen replacement therapy has obvious neuroprotective effects against stroke, it is always accompanied with several adverse effects and undesired outcomes. Genistein, a natural phytoestrogen, has been indicated to be a potential neuroprotective alternative for postmenopausal women against stroke. However, the role and mechanism of genistein’s neuroprotective effects against stroke in ovariectomized rats have rarely been explored.

Methods: In this study, ovariectomized rats were treated with genistein (10 mg/kg) or vehicle daily for two weeks before they received middle cerebral artery occlusion (MCAO) and reperfusion. After 72 hours of reperfusion, the neurological function was evaluated by Garcia test, infarct volume was detected by 2,3,5-triphenyltetrazolium chloride staining, and neuronal damage was detected by Nissl staining. In addition, ROS production and the expression of Nrf2, NQO1 and cleaved-Caspase3 in the ischemic penumbra were detected.

Results: The results showed that genistein treatment significantly improved the neurological outcome, reduced infarct volume, increased Nrf2 and NQO1 expression, and reduced ROS production and cleaved-Caspase3 expression in ovariectomized rats.

Discussion: Our findings indicated that treatment with genistein could alleviated oxidative stress injury induced by cerebral ischemia in ovariectomized rats via promoting Nrf2 and NQO1 expression, which provide a new molecular mechanism for the neuroprotective effects of genistein against stroke in postmenopausal women.     

Remote limb ischemic postconditioning protects mouse brain against cerebral ischemia/reperfusion injury via upregulating expression of Nrf2, HO-1 and NQO-1 in mice

Remote ischemic postconditioning (RIPostC) is a promising therapeutic intervention, which has been discovered to reduce ischemia/reperfusion (I/R) injury in heart, kidney, brain and skeletal muscle experimentally. However, its potential protective mechanisms have not been well elucidated. The aim of this study was to investigate the protective effect of RIPostC in cerebral I/R injury and explore the new putative mechanisms of neuroprotection elicited by it. Focal cerebral ischemia was induced by transient middle cerebral artery occlusion (tMCAO) in male CD1 mice. RIPostC was generated by three cycles of 5-min reperfusion/5-min occlusion of the bilateral femoral artery on the bilateral limbs at the onset of middle cerebral artery reperfusion. RIPostC significantly improved neurological outcome, lessened infarct volume and brain edema, upregulated the expression of Nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 (HO-1) and quinone oxidoreductase-1 (NQO-1) and activity of superoxide dismutase (SOD), and downregulaed the formation of malondialdehyde (MDA) (p < 0.05). Taken together, these findings demonstrated that RIPostC protected the brain from I/R injury after focal cerebral ischemia by reducing oxidative stress and activating the Nrf2–ARE (antioxidant response element) pathway.     

In vivo and in vitro characterization of a novel neuroprotective strategy for stroke: ischemic postconditioning.

As clinical trials of pharmacological neuroprotective strategies in stroke have been disappointing, attention has turned to the brain's own endogenous strategies for neuroprotection. Recently, a hypothesis has been offered that modified reperfusion subsequent to a prolonged ischemic episode may also confer ischemic neuroprotection, a phenomenon termed 'postconditioning'. Here we characterize both in vivo and in vitro models of postconditioning in the brain and offer data suggesting a biological mechanism for protection. Postconditioning treatment reduced infarct volume by up to 50% in vivo and by approximately 30% in vitro. A duration of 10 mins of postconditioning ischemia after 10 mins of reperfusion produced the most effective postconditioning condition both in vivo and in vitro. The degree of neuroprotection after postconditioning was equivalent to that observed in models of ischemic preconditioning. However, subjecting the brain to both preconditioning as well as postconditioning did not cause greater protection than each treatment alone. The prosurvival protein kinases extracellular signal-regulated kinase (ERK), p38 mitogen-activated protein kinase (MAPK), and Akt show prolonged phosphorylation in the cortex of postconditioned rats. Neuroprotection after postconditioning was inhibited only in the presence of LY294002, which blocks Akt activation, but not U0126 or SB203580, which block ERK and P38 MAP kinase activity. In contrast, preconditioning-induced protection was blocked by LY294002, U0126, and SB203580. Our data suggest that postconditioning may represent a novel neuroprotective approach for focal ischemia/reperfusion, and one that is mediated, at least in part, by the activation of the protein kinase Akt.     

Carotid endarterectomy for ameliorating the symptoms of transient ischemic attack☆○ A six-month postoperative follow-up

BACKGROUND: Carotid endarterectomy has certain risks, but it has obvious effects on preventing the occurrence of stroke. OBJECTIVE: To identify the effects of carotid endarterectomy on ameliorating the clinical symptoms and physical signs of patients with cerebral ischemia. DESIGN: A follow-up study. SETTING: Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology. PARTICIPANTS: Sixteen patients with carotid atherosclerotic stenosis accompanied by ischemic symptoms were selected from the Department of Vascular Surgery, Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology from March 2005 to May 2007. There were 11 males and 5 females, aged from 40 to 81 years old with a mean age of 60 years old, and they were all clearly diagnosed by carotid color Doppler ultrasound. Informed consent was obtained from all the patients. The study was approved by the hospital ethical committee. METHODS: ① All the 16 patients were performed with unilateral stripping of arteriosclerotic plaque and Carotid endarterectomy, and 6 of them with bilateral stenosis was operated on the side with more serious stenosis. ② The clinical symptoms, physical signs before and after operation, and the operative complications were observed. ③ The patients were followed up for 6 months postoperatively. The smoothness of carotid arteries was detected with color Doppler ultrasound. The degrees of satisfaction to the quality of living were evaluated. MAIN OUTCOME MEASURES: ① Amelioration of clinical symptoms postoperatively; ② Smoothness of carotid arteries postoperatively; ③ Degrees of satisfaction to the quality of living; ④ Postoperative complications. RESULTS: All the 16 patients were involved in the final analysis of results. ① Amelioration of clinical symptoms and physical signs: The postoperative muscle strengths of 3 patients with stroke history were significantly ameliorated; For the 8 patients with TIA symptoms, and the symptoms disappeared completely in 6 cases of them; For the 5 patients with atypical nervous symptoms, the symptoms disappeared completely in 3 cases, and obviously alleviated in 2 cases. ② All the patients were good in smoothness of carotid arteries. ③ The degree of satisfaction to the quality of living was a little satisfied in 2 patients, very satisfied in 1 patient, and satisfied in the others. ④ Postoperative complications: The complications were injury of hypoglossal nerve in 4 patients (25%) and injury of recurrent laryngeal nerve in 1 patient (6%), and the complications recovered or turned better after conservative treatments for 1–3 months. CONCLUSION: Carotid endarterectomy can ameliorate the symptoms and physical signs of patients with cerebral ischemia, and it has mild postoperative complications.     

Glucagon-like peptide-1 receptor agonists as neuroprotective agents for ischemic stroke: a systematic scoping review

Stroke mortality and morbidity is expected to rise. Despite considerable recent advances within acute ischemic stroke treatment, scope remains for development of widely applicable neuroprotective agents. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), originally licensed for the management of Type 2 Diabetes Mellitus, have demonstrated pre-clinical neuroprotective efficacy in a range of neurodegenerative conditions. This systematic scoping review reports the pre-clinical basis of GLP-1RAs as neuroprotective agents in acute ischemic stroke and their translation into clinical trials. We included 35 pre-clinical studies, 11 retrospective database studies, 7 cardiovascular outcome trials and 4 prospective clinical studies. Pre-clinical neuroprotection was demonstrated in normoglycemic models when administration was delayed by up to 24 h following stroke induction. Outcomes included reduced infarct volume, apoptosis, oxidative stress and inflammation alongside increased neurogenesis, angiogenesis and cerebral blood flow. Improved neurological function and a trend towards increased survival were also reported. Cardiovascular outcomes trials reported a significant reduction in stroke incidence with semaglutide and dulaglutide. Retrospective database studies show a trend towards neuroprotection. Prospective interventional clinical trials are on-going, but initial indicators of safety and tolerability are favourable. Ultimately, we propose that repurposing GLP-1RAs is potentially advantageous but appropriately designed trials are needed to determine clinical efficacy and cost-effectiveness.     

Neuroprotection by glutamate oxaloacetate transaminase in ischemic stroke: an experimental study

As ischemic stroke is associated with an excessive release of glutamate into the neuronal extracellular space, a decrease in blood glutamate levels could provide a mechanism to remove it from the brain tissue, by increasing the brain–blood gradient. In this regard, the ability of glutamate oxaloacetate transaminase (GOT) to metabolize glutamate in blood could represent a potential neuroprotective tool for ischemic stroke. This study aimed to determine the neuroprotective effects of GOT in an animal model of cerebral ischemia by means of a middle cerebral arterial occlusion (MCAO) following the Stroke Therapy Academic Industry Roundtable (STAIR) group guidelines. In this animal model, oxaloacetate-mediated GOT activation inhibited the increase of blood and cerebral glutamate after MCAO. This effect is reflected in a reduction of infarct size, smaller edema volume, and lower sensorimotor deficits with respect to controls. Magnetic resonance spectroscopy confirmed that the increase of glutamate levels in the brain parenchyma after MCAO is inhibited after oxaloacetate-mediated GOT activation. These findings show the capacity of the GOT to remove glutamate from the brain by means of blood glutamate degradation, and suggest the applicability of this enzyme as an efficient and novel neuroprotective tool against ischemic stroke.     

Bcl-2 enhances the formation of newborn striatal long-projection neurons in adult rat brain after a transient ischemic stroke

Objective It has been reported that B-cell lymphoma 2(Bcl-2) enhances neurogenesis as well as supporting axonal growth after injury.In the present study,we investigated whether Bcl-2 overexpression plays a role in the formation of newborn striatonigral projection neurons in the adult rat brain after transient middle cerebral artery occlusion (MCAO).Methods We infused human Bcl-2-expressing plasmid(pBcl-2) into the lateral ventricle immediately after 30 min of MCAO,injected 5’-bromodeoxyuridine(BrdU) intraperitoneally to label proliferative cells,and microinjected fluorogold(FG) into the substantia nigra at 11 weeks of reperfusion followed by multiple immunostaining of striatonigral projection neurons at 12 weeks.Results We found that pBcl-2 treatment significantly increased the number of newborn neurons(BrdU~+-NeuN~+) in the striatum ipsilateral to the MCAO.We further detected newborn striatonigral projection neurons(BrdU~+-FG~+-NeuN~+) in the ipsilateral striatum at 12 weeks.More interestingly,the number of newborn striatonigral projection neurons(BrdU~+-FG~+) was significantly increased by pBcl-2 treatment compared to that by pEGFP, a control plasmid.Conclusion Taken together,we found that Bcl-2 overexpression in the brain enhanced the generation of newborn striatonigral projection neurons.This provides a potential strategy for promoting the reestablishment of neural networks and brain repair after ischemic injury.     

Synergistic combinatorial stroke therapy: A quantal bioassay of a GABA agonist and a glutamate antagonist

We sought to prolong the window for stroke treatment using synergistic combinatorial therapy. We used the intraluminal filament occlusion model in rats to cause focal cerebral ischemia and a quantal bioassay to measure efficacy. The GABA agonist muscimol and the glutamate antagonist MK-801 were used alone and in combination at various times after ischemia onset. At progressively longer treatment delay intervals (30, 60, 75, 120, 240, and 360 min), higher doses of the single drugs were required to achieve neuroprotection. In contrast, the combination 1.0 mg/kg muscimol plus 0.5 mg/kg MK-801 was effective at all delay intervals studied except the longest (P < 0.05 at each time). After 240 min from ischemia onset, the combination was more effective than either single agent (P < 0.05 for each drug dose), suggesting synergism. The neuroprotective effect could not be demonstrated using morphometry. The treatment effects were probably not due to hypothermia because brain temperatures recorded in awake, unregulated subjects remained normo- or slightly hyperthermic following all treatments. Awake subjects kept on a heating pad exhibited mild brain hyperthermia. The combination caused a drop and MK-801 caused a significant increase in mean arterial blood pressure (main effects F(5,172) = 29, P < 0.0001). The combination of a GABA agonist and glutamate antagonist appears to possess synergistic neuroprotective effects when treatment is delayed up to 240 min following the onset of cerebral ischemia. Temperature regulation causes hyperthermia in awake subjects. The quantal bioassay is one method suitable for studies of synergistic stroke therapy.     

Permanent or transient chronic ischemic stroke in the non-human primate: behavioral, neuroimaging, histological, and immunohistochemical investigations

Using multimodal magnetic resonance imaging (MRI), behavioral, and immunohistochemical analyses, we examined pathological changes at the acute, sub-acute, and chronic stages, induced by permanent or temporary ischemia in the common marmoset. Animals underwent either permanent (pMCAO) or 3-h transient (tMCAO) occlusion of the middle cerebral artery (MCAO) by the intraluminal thread approach. MRI scans were performed at 1 h, 8, and 45 days after MCAO. Sensorimotor deficits were assessed weekly up to 45 days after MCAO. Immunohistological studies were performed to examine neuronal loss, astrogliosis, and neurogenesis. Remote lesions were analyzed using retrograde neuronal tracers. At day 8 (D8), the lesion defined on diffusion tensor imaging (DTI)–MRI and T2-MRI was significantly larger in pMCAO as compared with that in the tMCAO group. At D45, the former still displayed abnormal signals in T2-MRI. Post-mortem analyses revealed widespread neuronal loss and associated astrogliosis to a greater extent in the pMCAO group. Neurogenesis was increased in both groups in the vicinity of the lesion. Disconnections between the caudate and the temporal cortex, and between the parietal cortex and the thalamus, were observed. Sensorimotor impairments were more severe and long-lasting in pMCAO relative to tMCAO. The profile of brain damage and functional deficits seen in the marmoset suggests that this model could be suitable to test therapies against stroke.     

Perioperative stroke: A perspective on challenges and opportunities for experimental treatment and diagnostic strategies

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.     

MAP2 immunostaining in thick sections for early ischemic stroke infarct volume in non-human primate brain

The delineation of early infarction in large gyrencephalic brain cannot be accomplished with triphenyl-tetrazolium chloride (TTC) due to its limitations in the early phase, nor can it be identified with microtubule-associated protein 2 (MAP2) immunohistochemistry, due to the fragility of large thin sections. We hypothesize that MAP2 immunostaining of thick brain sections can accurately identify early ischemia in the entire monkey brain.Using ischemic brains of one rat and three monkeys, a thick-section MAP2 immunostaining protocol was developed to outline the infarct region over the entire non-human primate brain. Comparison of adjacent thick and thin sections in a rat brain indicated complete correspondence between ischemic regions (100.4 mm³ ± 1.2%, n = 7, p = 0.44). Thick sections in monkey brain possessed the increased structural stability necessary for the extensive MAP2 immunostaining procedure permitting quantification of the ischemic region as a percent of total monkey brain, giving infarct volumes of 11.4, 16.3, and 19.0% of total brain. Stacked 2D images of the intact thick brain tissue sections provided a 3D representation for comparison to MRI images. The infarct volume of 16.1 cm³ from the MAP2 sections registered with MRI images agreed well with the volume calculated directly from the stained sections of 16.6 cm³.Thick brain tissue section MAP2 immunostaining provides a new method for determining infarct volume over the entire brain at early time points in a non-human primate model of ischemic stroke.     

Antiplatelet strategy for acute ischemic stroke: A mini review

Transient ischemic attacks and minor ischemic strokes have a high risk of an unstable clinical course in the initial 48-72 h after symptom onset. Early antiplatelet treatment is recommended to treat most patients with acute ischemic stroke because few patients can be treated with thrombolysis due to the limit of strict indications, such as a time window. Antiplatelets aim to prevent recurrence or deterioration of stroke. The guidelines recommend the use of aspirin in the acute stage based on two clinical trials. However, some patients still developed recurrence or deterioration of stroke despite timely aspirin administration. Thus, the question remains unclear whether another effective and safe antiplatelet strategy for the treatment of acute ischemic stroke exists. Growing evidence shows that combination antiplatelets may be superior to mono antiplatelets in the treatment of acute ischemic stroke.