Neuroprotection in acute ischemic stroke – current status

With the growing understanding of the mechanism of cell death in ischemia, new approaches for treatment such as neuroprotection have emerged. The basic aim of this strategy is to interfere with the events of the ischemic cascade, blocking the pathological processes and preventing the death of nerve cells in the ischemic penumebra. This concept involves inhibition of the pathological molecular events which eventually leads to the influx of calcium, activation of free radicals and neuronal death. Despite encouraging data from experimental animal models, all clinical trials of neuroprotective therapies have to date been unsuccessful. This article reviews some of the reasons for the failure of neuroprotection in the clinical trials so far. Despite all the negative reports, we believe it would be wrong to give up at this point, since there is still reasonable hope of finding an effective neuroprotection for stroke.     

Neurogenic Neuroprotection

1. Stimulation of the rostral-ventromedial pole of the cerebellar fastigial nucleus exerts powerful effects on systemic and cerebral circulation.2. Excitation of fibers passing through the fastigial nucleus evokes sympathoactivation and increases in arterial pressure.3. Increase in cerebral blood flow evoked by excitation of fibers passing through the FN is mediated by intrinsic brain mechanisms independently of metabolism.4. Excitation of the fastigial nucleus neurons in contrast decreases arterial pressure and cerebral blood flow. The latter probably is secondary to the suppression of brain metabolism.5. Excitation of the fastigial nucleus neurons significantly decreases damaging effects of focal and global ischemia on the brain.6. The fastigial nucleus-evoked neuroprotection can be conditioned: 1-h stimulation protects the brain for up to 3 weeks.7. Other brain structures such as subthalamic cerebrovasodilator area and dorsal periaqueductal gray matter also produce long-lasting brain salvage when stimulated.8. More than one mechanism may account for neurogenic neuroprotection.9. Early neuroprotection, which develops immediately after the stimulation, involves opening of potassium channels.10. Delayed long-lasting neuroprotection may involve changes in genes expression resulting in suppression of inflammatory reaction and apoptotic cascade.11. It is conceivable that intrinsic neuroprotective system exists within the brain, which renders the brain more tolerant to adverse stimuli when activated.12. Knowledge of the mechanisms of neurogenic neuroprotection will allow developing new neuroprotective approaches.     

CD36: A multi-modal target for acute stroke therapy

A role for CD36 in the pathogenesis of atherosclerosis, inflammation and lipid metabolism has been well-documented. However, little is known about the role of CD36 in cerebral ischemia. The intent of this review is to develop the concept that CD36, whose functions have been implicated in other pathological events, is a prototypic inflammatory receptor that contributes to the pathogenesis of cerebral ischemia. The importance of CD36 as a treatment target is indicated by the fact that many treatment strategies that are effective in experimental models of stroke exhibit little or no efficacy in clinical trials. The failure of clinical trials may be due to the use of animal models of stroke that do not reflect traditional risk factors for stroke in humans. The discussion will be focused on two risk factors, hyperlipidemia and diabetes, that modulate CD36 responses. Blocking the expression and function of CD36 by pharmacological or genetic means will provide insight not only toward identifying CD36 as a novel molecular target but also for developing effective therapeutic strategies to treat stroke victims. More importantly, coupling clinically relevant conditions with CD36-mediated ischemic injury may provide an appropriate animal model paradigm and develop a scientific understanding that could lead to clinical translational studies involving human subjects.     

缺血性脑卒中溶栓药物研究进展

缺血性脑卒中是一种高发病率、高死亡率的重大健康危机。溶栓药物能快速溶解血栓、减少出血副作用、实现血管再通,对缺血性脑卒中治疗起到关键性的作用。重组组织纤溶酶原激活剂(rtPA)是FDA批准的唯一缺血性脑卒中药物,但在临床使用中有诸多限制。近年来,基于tPA的溶栓药物及治疗策略发展迅速,文中结合笔者课题组及目前国内外的相关研究成果,回顾了该领域的最新进展,为新型溶栓药物发展提供科学依据和思路。     

Neuroprotective actions of a histidine analogue in models of ischemic stroke

Histidine is a naturally occurring amino acid with antioxidant properties, which is present in low amounts in tissues throughout the body. We recently synthesized and characterized histidine analogues related to the natural dipeptide carnosine, which selectively scavenge the toxic lipid peroxidation product 4-hydroxynonenal (HNE). We now report that the histidine analogue histidyl hydrazide is effective in reducing brain damage and improving functional outcome in a mouse model of focal ischemic stroke when administered intravenously at a dose of 20 mg/kg, either 30 min before or 60 min and 3 h after the onset of middle cerebral artery occlusion. The histidine analogue also protected cultured rat primary neurons against death induced by HNE, chemical hypoxia, glucose deprivation, and combined oxygen and glucose deprivation. The histidine analogue prevented neuronal apoptosis as indicated by decreased production of cleaved caspase-3 protein. These findings suggest a therapeutic potential for HNE-scavenging histidine analogues in the treatment of stroke and related neurodegenerative conditions.     

银杏叶提取物促进脑缺血半暗带神经元自噬提高神经保护作用

银杏叶提取物(ginkgo biloba extract-761,EGb-761)注射液在中国常作为辅助药物被用于治疗脑卒中,但是,其潜在的细胞和药理机制尚未完全了解.该研究旨在探讨EGb-761是否通过调节缺血性脑卒中半暗带神经元的自噬从而发挥保护作用.采用雄性SD大鼠大脑中动脉闭塞(middle cerebral ...     

局部动脉注射阿替普酶溶栓治疗急性缺血性脑卒中的临床效果

目的分析局部动脉注射阿替普酶溶栓治疗急性缺血性脑卒中的临床效果。方法本溪市中心医院从2011年1月至2013年10月期间共收治90例急性缺血性脑卒中患者,患者在入院的6 h内接受了阿替普酶溶栓的局部动脉注射治疗,观察总结患者接受治疗24 h和3个月内的疗效,并依据临床观察和NHISS评分结果来评价患者的神经功能恢复情况。结果 90例患者当中有58例前循环缺血患者和32例后循环缺血患者,在接受溶栓治疗的24 h内有64例患者神经功能得到良好恢复,占总数的71.11%,还有26例患者神经功能不良,占总数的28.89%;3个月后通过随访了解到有82例患者神经功能良好,占总数的91.11%,8例患者功能仍然处于不良状态,占总数的8.89%,治疗前后患者的神经功能恢复比较差异具有统计学意义（P〈0.05%）。结论局部动脉注射阿替普酶溶栓治疗急性缺血性脑卒中,患者能够得到有效恢复,疗效显著,值得在临床上推广使用。     

Circadian rhythms may not influence the outcomes of thrombolysis in patients with ischemic stroke: A study from China

ABSTRACT

Circadian rhythms can affect physical or mental activities as well as the time of stroke onset. The impact of circadian rhythms on acute ischemic stroke (AIS) patients treated by recombinant alteplase (rt-PA) is still incongruent. This study aims to consider whether the outcomes of thrombolysis differ depending on stroke onset time and rt-PA infusion time in patients with AIS. A total of 447 AIS patients, who underwent rt-PA intravenous infusion within 4.5 hours after stroke onset, were enrolled in this study consecutively from June 2010 through December 2016. All of the patients were grouped based on the stroke onset time and rt-PA infusion time into two exact 12-hour intervals as daytime (06:01–18:00) and nighttime (18:01–06:00) and further divided into four subgroups at 6-hour time intervals (00:01–06:00, 06:01–12:00, 12:01–18:00 and 18:01–24:00). Major neurological improvement at 1 hour, 24 hours and 7 days, 7-day mortality rate and 24-hour hemorrhage transformation was recorded. The results showed that a total of 295 patients (66.4%) appeared with AIS and 252 (56.4%) were treated during daytime. Higher NIHSS at admission was observed when stroke occurred in nighttime, especially during 00:01–06:00. Patients with stroke onset in nighttime especially during 18:01–24:00 had a significant shorter onset-door time and onset-needle time. No differences of the major neurological improvement at 1 hour, 24 hours and 7 days, 24-hour hemorrhagic transformation and 7-day fatality rate were found among either 12-hour time frames or 6-hour time frames according to the time of stroke onset or rt-PA infusion. In conclusion, there was no evidence to predict that circadian rhythms could influence the outcomes of AIS patients treated with rt-PA in China, although stroke onset during nighttime might aggravate neurological impairment before treatment. Further, multicenter and prospective clinical trials with larger number of subjects are still needed to draw more reliable conclusions.     

The Mitochondrial Permeability Transition as a Target for Neuroprotection

Mitochondria serve as checkpoints and amplifiers on cell death pathways. In the central nervous system, mitochondrial involvement seems essential for normal expression of cell death phenotypes, and interference with these pathways thus seems a reasonable approach to neuroprotection. We have been involved in examining the potential involvement of the mitochondrial permeability transition (mPT) as one of several possible mechanisms by which mitochondria may be drawn into these death cascades. This possibility, though still controversial, is supported by evidence that factors that may stimulate mPT induction are associated with some forms of cell death (e.g., in stroke) and are modulated by diseases of the central nervous system (e.g., Huntington's). Evidence of neuroprotection seen with compounds such as N-Met-Val cyclosporine also support this possibility.     

丙戊酸与缺血性脑卒中相关研究进展

动脉粥样硬化和缺血性脑损伤是防治缺血性脑卒中所面临的两大难题,而细胞炎症损伤是它们的共同诱因。丙戊酸作为组蛋白去乙酰化酶抑制剂,具有抑制细胞炎症因子释放及保护神经的作用,所以丙戊酸可能是防治缺血性脑卒中的潜在治疗药物。本文从组蛋白去乙酰化酶对缺血性脑卒中的影响以及丙戊酸的抗炎机制两个方面进行综述。     

Efficacy of intravenous thrombolysis combined with mechanical stent interventional thrombectomy on acute ischemic stroke

BackgroundTo investigate the efficacy and safety of intravenous thrombolysis combined with mechanical stent interventional thrombectomy in the treatment of acute ischemic stroke.MethodsA retrospective analysis was carried out for clinical data of 118 patients with acute ischemic stroke. The patients enrolled were divided into control group (recombinant tissue plasminogen activator (rt-PA) intravenous thrombolysis) and thrombectomy group (mechanical stent interventional thrombectomy based on rt-PA intravenous thrombolysis). The vascular recanalization rate and clinical efficacy after treatment were compared between the two groups. National Institutes of Health Stroke Scale (NIHSS) was used to identify the degree of neurological impairment in all patients before and after treatment, and Barthel Index was used to assess their activity of daily living. Moreover, the changes in the levels of T-lymphocyte subpopulation in peripheral blood and immuno-inflammatory factors before and after treatment were compared, and prognosis of patients and incidence of adverse reactions were recorded.ResultsThe response rate inthrombectomy group (93.2%) was significantly better than that in control group (76.3%). The NIHSS sore and modified Rankin scale (mRS) score after treatment were significantly lower than those before treatment, while the Barthel Index after treatment was distinctly higher than that before treatment. The NIHSS score and mRS score in thrombectomy group obviously declined compared with those in control group at 1 month after treatment. The Barthel Index in thrombectomy group was obviously higher than that in control group at 1 month and 2 months after treatment. Levels of cluster of differentiation 3 (CD3)+, CD3+CD4+, CD4+/CD8+ and natural killer (NK) cells in peripheral blood at 6 months after treatment evidently rose compared with those before treatment, while level of CD3+CD8+ evidently declined compared with that before treatment. In thrombectomy group, levels of CD3+, CD3+CD4+, CD4+/CD8+ and NK cells were markedly higher than those in control group, while the level of CD3+CD8+ was markedly lower than that in control group. Besides, in thrombectomy group, levels of serum osteopontin (OPN), malondialdehyde (MDA) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were evidently lower than those in control group at 1 month after treatment, while the level of serum superoxide dismutase (SOD) was evidently higher than that in control group. Compared with that in control group, the acute vascular reocclusion rate in thrombectomy group was significantly decreased at 3 months after treatment (10.2% vs. 22.0%).ConclusionsIntravenous thrombolysis combined with mechanical stent interventional thrombectomy can effectively promote the vascular recanalization, improve the neurological function and activity of daily living of patients, reinforce the immunological function, inhibit the oxidative stress response and improve the prognosis of patients.     

Neuroprotection against neurodegenerative diseases

Neuronal death is directly implicated in the pathogenesis of neurodegenerative diseases (NDDs). NDDs cannot be cured because the mechanisms underlying neuronal death are too complicated to be therapeutically suppressed. Neuroprotective factors, such as neurotrophins, certain growth factors, neurotrophic cytokines, and short neuroprotective peptides, support neuronal survival in both physiological and pathological conditions, suggesting that these factors may be good drug candidates for NDDs. We recently generated a novel neuroprotective peptide named Colivelin by attaching activity-dependent neurotrophic factor (ADNF) to the N-terminus of a potent Humanin derivative, AGA-(C8R)HNG17. HN was originally identified from an Alzheimer’s disease (AD) brain as an endogenous neuroprotective peptide that suppresses AD-relevant toxicity. Colivelin protects neurons from death relevant to NDDs by activating two independent prosurvival signals: an ADNF-mediated Ca²⁺/calmodulin-dependent protein kinase IV pathway and an HN-mediated STAT3 pathway. The neuroprotective effect of Colivelin provides novel insights into therapy for NDDs. An erratum to this article is available at .     

Neuroprotection conferred by post‐ischemia ethanol therapy in experimental stroke: an inhibitory effect on hyperglycolysis and NADPH oxidase activation

Ethanol provides neuroprotection following ischemia/reperfusion. This study assessed ethanol's effect on hyperglycolysis and NADPH oxidase (NOX) activation. Adult, male Sprague–Dawley rats were subjected to middle cerebral artery occlusion (MCAO) for 2 h. Three sets of experiments were conducted to determine ethanol's effect on (i) conferring neuroprotection by measuring infarct volume and neurological deficits 24 h post reperfusion; (ii) cerebral glucose metabolism and lactic acidosis by measuring brain and blood glucose concentrations and protein expression of glucose transporter 1 and 3 (GLUT1, GLUT3), phosphofructokinase (PFK), as well as lactic acidosis by measuring lactate dehydrogenase (LDH), and lactate; and (iii) nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) activation by detecting enzymatic activity and subunit expression at 3 h after reperfusion. When administered upon reperfusion, ethanol (1.5 g/kg) reduced infarct volume by 40% (p < 0.01) and neurological deficits by 48% at 24 h post reperfusion while reducing (p < 0.01) elevations in glycolytic protein expression and lactate levels during early reperfusion (3 h). Ethanol increased the reductions in cerebral glucose concentration at 3 h post reperfusion by 64% (p < 0.01) while enhancing (p < 0.01) post stroke blood glucose concentration, suggesting a reduced cellular glucose uptake and utilization. Ethanol decreased (p < 0.01) stroke‐induced NOX activation by reducing enzymatic activity and gp91^phox expression by 45% and 38%, respectively. Post‐ischemia ethanol treatment exerts neuroprotection through attenuation of hyperglycolysis and associated NOX activation. Because of the lack of associated hypoglycemia and selectivity toward decreasing cerebral metabolism, further investigation of ethanol's use as a post‐stroke therapy, especially in the context of hyperglycemia, seems warranted.     

Effects of thrombolysis within 6 hours on acute cerebral infarction in an improved rat embolic middle cerebral artery occlusion model for ischaemic stroke

Recombinant tissue plasminogen activator (rt‐PA) is the first‐line drug for revascularization in acute cerebral infarction (ACI) treatment. In this study, an improved rat embolic middle cerebral artery occlusion model for ischaemic stroke was used and the rats were killed on the first, third and seventh day after model establishment. Increases in infarct volume were significantly less in the thrombolytic group than in the conventional group at every time‐point. The microvascular density (MVD) in the thrombolytic group was significantly higher than that in the conventional group at every time‐point, especially on the seventh day. Increases in the expressions of neuronal nitric‐oxide synthase (NOS) and caspase‐3 in the ischaemic region and in the nitric oxide contents, malondialdehyde contents, and inducible NOS activities in the cortex of infarct side were significantly less in the thrombolytic group than in the conventional group. Furthermore, decreases in the superoxide dismutase activities in the thrombolytic group were significantly less than those in the conventional group. In conclusion, thrombolytic rt‐PA therapy within a broadened therapeutic window (6 hours) could significantly decrease the infarct volume after ACI, possibly by increasing MVD in the ischaemic region, decreasing apoptotic molecule expression, and alleviating the oxidative stress response.     

Neuroprotection or increased brain damage mediated by temperature in stroke is time dependent

The control of temperature during the acute phase of stroke may be a new therapeutic target that can be applied in all stroke patients, however therapeutic window or timecourse of the temperature effect is not well established. Our aim is to study the association between changes in body temperature in the first 72 hours and outcome in patients with ischemic (IS) and hemorrhagic (ICH) stroke. We prospectively studied 2931 consecutive patients (2468 with IS and 463 with ICH). Temperature was obtained at admission, and at 24, 48 and 72 hours after admission. Temperature was categorized as low (<36°C), normal (36–37°C) and high (>37°C). As the main variable, we studied functional outcome at 3 months determined by modified Rankin Scale.Temperature in stroke patients is higher than in controls, and increases gradually in the first 72 hours after stroke. A positive correlation between temperature and stroke severity determined by NIHSS was found at 24 and 48 hours, but not at admission or 72 hours. In a logistic regression model, high temperature was associated with poor outcome at 24 hours (OR 2.05, 95% CI 1.59–2.64, p<0.0001) and 48 hours (OR 1.93, 95% CI 1.08–2.34, p = 0.007), but not at admission or 72 hours.Temperature increases in patients with stroke in the first 72 hours, with the harmful effect of high temperature occurring in the first 48 hours. The neuroprotective effect of low temperature occurs within the first 24 hours from stroke onset.     

Neuroprotection of aucubin in primary diabetic encephalopathy

Hippocampal neuronal apoptosis accompanied by impairment of cognitive function occurs in primary diabetic encephalopathy. In this study, we investigated the neuroprotective mechanism of the iridoid glycoside, aucubin, using rats (n=8). Diabetes mellitus was induced in the rats by intraperitoneal (i.p.) injection of streptozotocin (60 mg/kg body weight). After 65 d, half of the DM rats were administered aucubin (5 mg/kg; i.p.) for 15 d, yielding treatment DM A. A third group of rats received no strepto- zotocin or aucibin, and served as controls (CON). Encephalopathy was assessed using Y-maze be- havioral testing. Rats were euthanized on Day 87, and hippocampi were excised for visual (light and transmission electron microscopic) and immunochemical (Western blot; immunohistochemical) as- sessments of the CA1 subfield for apoptosis and expression of regulatory proteins Bcl-2 and Bax. Treatment responses to all the parameters examined (body weight, plasma glucose, Y-maze error rates, pyramidal cell ultrastructure, proportions of apoptotic cells, levels of expression of Bcl-2 and Bax, and survivability of neuronal cells) were identical: there were highly significant differences between DM and CON groups (P<0.001), but the effects were significantly moderated (P<0.01) in DM A compared with DM. These findings confirm the association of apoptosis with the encephalopathic effects of diabetes mellitus, and suggest a major role of the expression levels of Bcl-2 and Bax in the regulation of apop- totic cell death. All of the results suggest that aucubin could effectively inhibit apoptosis by modulating the expressions of Bcl-2 and Bax genes.     

Exercise-Induced Neuroprotection in SMA Model Mice: A Means for Determining New Therapeutic Strategies

Due to the prevalence of neuromuscular disorders such as amyotrophic lateral sclerosis and spinal muscular atrophy in modern societies, defining new and efficient strategies for the treatment of these two neurodegenerative diseases has become a vital and still unfulfilled urge. Several lines of experimental evidence have emphasized the benefits of regular exercise training in mouse models for these affections in terms of life span increase and improvement of both motor capacities and motoneuron survival. Identifying molecules that could mimic the neuroprotective effects of exercise represents a promising way to find novel therapies. Some of the effects of exercise are caused by the overproduction of circulating neurotrophic factors, such as IGF-I, whereas others may be due to modifications of the intrinsic properties of the motoneurons within the spinal cord. The causal relationship that links these potential effects of exercise training and the improvement of motor capacity and life span expectancy is consequently discussed.     

Citicoline (CDP‐choline) increases Sirtuin1 expression concomitant to neuroprotection in experimental stroke

CDP‐choline has shown neuroprotective effects in cerebral ischemia. In humans, although a recent trial International Citicoline Trial on Acute Stroke (ICTUS) has shown that global recovery is similar in CDP‐choline and placebo groups, CDP‐choline was shown to be more beneficial in some patients, such as those with moderate stroke severity and not treated with t‐PA. Several mechanisms have been proposed to explain the beneficial actions of CDP‐choline. We have now studied the participation of Sirtuin1 (SIRT1) in the neuroprotective actions of CDP‐choline. Fischer rats and Sirt1^?/? mice were subjected to permanent focal ischemia. CDP‐choline (0.2 or 2 g/kg), sirtinol (a SIRT1 inhibitor; 10 mg/kg), and resveratrol (a SIRT1 activator; 2.5 mg/kg) were administered intraperitoneally. Brains were removed 24 and 48 h after ischemia for western blot analysis and infarct volume determination. Treatment with CDP‐choline increased SIRT1 protein levels in brain concomitantly to neuroprotection. Treatment with sirtinol blocked the reduction in infarct volume caused by CDP‐choline, whereas resveratrol elicited a strong synergistic neuroprotective effect with CDP‐choline. CDP‐choline failed to reduce infarct volume in Sirt1^?/? mice. Our present results demonstrate a robust effect of CDP‐choline like SIRT1 activator by up‐regulating its expression. Our findings suggest that therapeutic strategies to activate SIRT1 may be useful in the treatment of stroke.