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Khoshneviszadeh M, Henneicke S, Pirici D, Senthilnathan A, Morton L, Arndt P, Kaushik R, Norman O, Jukkola J, Dunay IR, Seidenbecher C, Heikkinen A, Schreiber S, Dityatev A. Microvascular damage, neuroinflammation and extracellular matrix remodeling in Col18a1 knockout mice as a model for early cerebral small vessel disease. Matrix Biol 2024; 128:39-64. [PMID: 38387749 DOI: 10.1016/j.matbio.2024.02.007] [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: 04/26/2023] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 02/24/2024]
Abstract
Collagen type XVIII (COL18) is an abundant heparan sulfate proteoglycan in vascular basement membranes. Here, we asked (i) if the loss of COL18 would result in blood-brain barrier (BBB) breakdown, pathological alterations of small arteries and capillaries and neuroinflammation as found in cerebral small vessel disease (CSVD) and (ii) if such changes may be associated with remodeling of synapses and neural extracellular matrix (ECM). We found that 5-month-old Col18a1-/- mice had elevated BBB permeability for mouse IgG in the deep gray matter, and intravascular erythrocyte accumulations were observed brain-wide in capillaries and arterioles. BBB permeability increased with age and affected cortical regions and the hippocampus in 12-month-old Col18a1-/- mice. None of the Col18a1-/- mice displayed hallmarks of advanced CSVD, such as hemorrhages, and did not show perivascular space enlargement. Col18a1 deficiency-induced BBB leakage was accompanied by activation of microglia and astrocytes, a loss of aggrecan in the ECM of perineuronal nets associated with fast-spiking inhibitory interneurons and accumulation of the perisynaptic ECM proteoglycan brevican and the microglial complement protein C1q at excitatory synapses. As the pathway underlying these regulations, we found increased signaling through the TGF-ß1/Smad3/TIMP-3 cascade. We verified the pivotal role of COL18 for small vessel wall structure in CSVD by demonstrating the protein's involvement in vascular remodeling in autopsy brains from patients with cerebral hypertensive arteriopathy. Our study highlights an association between the alterations of perivascular ECM, extracellular proteolysis, and perineuronal/perisynaptic ECM, as a possible substrate of synaptic and cognitive alterations in CSVD.
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Affiliation(s)
- Mahsima Khoshneviszadeh
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany; Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Solveig Henneicke
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany; Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Daniel Pirici
- Department of Histology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | | | - Lorena Morton
- Institute of Inflammation and Neurodegeneration, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany
| | - Philipp Arndt
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany; Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Rahul Kaushik
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany
| | - Oula Norman
- Faculty of Biochemistry and Molecular Medicine, University of Oulu, Finland
| | - Jari Jukkola
- Faculty of Biochemistry and Molecular Medicine, University of Oulu, Finland
| | - Ildiko Rita Dunay
- Institute of Inflammation and Neurodegeneration, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany; Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany; Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health (C-I-R-C), Jena-Magdeburg-Halle, Germany
| | - Constanze Seidenbecher
- Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany; Leibniz Institute for Neurobiology, Magdeburg, Germany; Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health (C-I-R-C), Jena-Magdeburg-Halle, Germany
| | - Anne Heikkinen
- Faculty of Biochemistry and Molecular Medicine, University of Oulu, Finland
| | - Stefanie Schreiber
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany; Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany; Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany; Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health (C-I-R-C), Jena-Magdeburg-Halle, Germany.
| | - Alexander Dityatev
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany; Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany; Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany.
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Bai M, Sun R, Cao B, Feng J, Wang J. Monocyte-related cytokines/chemokines in cerebral ischemic stroke. CNS Neurosci Ther 2023; 29:3693-3712. [PMID: 37452512 PMCID: PMC10651979 DOI: 10.1111/cns.14368] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/01/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023] Open
Abstract
AIMS Ischemic stroke is one of the leading causes of death worldwide and the most common cause of disability in Western countries. Multiple mechanisms contribute to the development and progression of ischemic stroke, and inflammation is one of the most important mechanisms. DISCUSSION Ischemia induces the release of adenosine triphosphate/reactive oxygen species, which activates immune cells to produce many proinflammatory cytokines that activate downstream inflammatory cascades to induce fatal immune responses. Research has confirmed that peripheral blood immune cells play a vital role in the immunological cascade after ischemic stroke. The role of monocytes has received much attention among numerous peripheral blood immune cells. Monocytes induce their effects by secreting cytokines or chemokines, including CCL2/CCR2, CCR4, CCR5, CD36, CX3CL1/CX3CR1, CXCL12(SDF-1), LFA-1/ICAM-1, Ly6C, MMP-2/9, NR4A1, P2X4R, P-selectin, CD40L, TLR2/4, and VCAM-1/VLA-4. Those factors play important roles in the process of monocyte recruitment, migration, and differentiation. CONCLUSION This review focuses on the function and mechanism of the cytokines secreted by monocytes in the process of ischemic stroke and provides novel targets for treating cerebral ischemic stroke.
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Affiliation(s)
- Meiling Bai
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ruize Sun
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Bin Cao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Juan Feng
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jue Wang
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
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Zhang X, Gong P, Chen S, Wan T, Wang X, Wang M, Zhou J, Xie Y, Jiang T. Endothelial Dysfunction and Parenchymal Hematoma in Ischemic Stroke Patients after Endovascular Thrombectomy. Cerebrovasc Dis 2023; 52:663-670. [PMID: 36972564 DOI: 10.1159/000530372] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Endothelial dysfunction (ED) may result in parenchymal injury and therefore worsen the outcomes of ischemic stroke. This study aimed to determine whether ED could predict parenchymal hematoma (PH) in ischemic stroke patients treated with endovascular thrombectomy (EVT). METHODS Patients with large artery occlusion in the anterior circulation and treated with EVT were prospectively enrolled from 2 stroke centers. Serum soluble intercellular adhesion molecule-1, soluble vascular cell adhesion molecule-1, soluble E-selectin, and von Willebrand factor (vWF) were tested and summed to a standardized score to reflect the levels of ED. PH was diagnosed according to the Heidelberg Bleeding Classification. RESULTS Of the 325 enrolled patients (mean age, 68.6 years; 207 men), 41 (12.6%) developed PH. Patients with PH had higher concentrations of soluble E-selectin, vWF, and ED sum score. After adjusting for demographic characteristics, National Institutes of Health Stroke Scale score, pretreatment Alberta stroke program early computed tomography score, and other potential confounders, the increased ED burden was associated with PH (odds ratio, 1.432; 95% confidence interval, 1.031-1.988; p = 0.032). Similar significant results were found in the sensitivity analysis. The multiple-adjusted spline regression model showed a linear association between the total ED score and PH (p = 0.001 for linearity). Adding the ED score to the conventional model significantly improved the risk prediction of PH (net reclassification improvement = 25.2%, p = 0.001; integrated discrimination index = 2.9%; p = 0.001). CONCLUSIONS This study demonstrated that ED might be related to PH. Introducing the ED score could increase the reliability of the PH risk model for stroke patients treated with EVT.
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Affiliation(s)
- Xiaohao Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China,
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China,
| | - Pengyu Gong
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Shuaiyu Chen
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Ting Wan
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiaoke Wang
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Meng Wang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yi Xie
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Teng Jiang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Landreth S, Teague AM, Jensen ME, Gulati S, Tryggestad JB. Impact of maternal diabetes exposure on soluble adhesion molecules in the offspring. Nutr Metab Cardiovasc Dis 2022; 32:1253-1258. [PMID: 35256229 PMCID: PMC9018574 DOI: 10.1016/j.numecd.2022.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/29/2021] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIMS Soluble adhesion molecules are associated with cardiovascular disease and increased in individuals with diabetes. This study assesses the impact of diabetes exposure in utero on the abundance of circulating adhesion molecules in cord serum and soluble adhesion molecules released from human umbilical vein endothelial cells (HUVEC) exposed to high glucose concentrations. METHODS AND RESULTS Women with and without diabetes were recruited. DM was diagnosed based on the American Diabetes Association criteria. Primary cultures of HUVEC were cultured in 5 mM and 25 mM glucose with 25 mM mannitol osmotic control. The soluble adhesion molecules, intracellular adhesion molecule (ICAM), vascular cell adhesion molecule (VCAM) and E-selectin were measured by ELISA in the cord blood serum and conditioned HUVEC media. The mothers with DM were older with higher BMI (p = 0.027 and 0.008, respectively). In a fully adjusted model, VCAM was significantly increased in the cord serum of infants born to mothers with diabetes (p = 0.046), but ICAM and E-selectin were not different. ICAM was also significantly correlated with maternal HbA1c (r2 = 0.16, p = 0.004) and cord serum non-esterified fatty acids (r2 = 0.08, p = 0.013). From the HUVEC media, the abundance of adhesion molecules was not different based on DM or high glucose exposure; however, VCAM abundance in the HUVEC supernatant was significantly correlated with ICAM (r2 = 0.27, p = 0.010) and cord serum c-peptide (R2 = 0.19, p = 0.043). CONCLUSIONS Alterations in soluble adhesion molecule abundance in infants exposed to the diabetic milieu of pregnancy may reflect early alterations in vascular function predicting future cardiovascular disease.
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Affiliation(s)
- Samantha Landreth
- Department of Pediatrics, Section of Diabetes/Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - April M Teague
- Department of Pediatrics, Section of Diabetes/Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Mary E Jensen
- Department of Pediatrics, Section of Diabetes/Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Shelly Gulati
- Department of Pediatrics, Section of Diabetes/Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jeanie B Tryggestad
- Department of Pediatrics, Section of Diabetes/Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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5
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Maglinger B, Sands M, Frank JA, McLouth CJ, Trout AL, Roberts JM, Grupke S, Turchan-Cholewo J, Stowe AM, Fraser JF, Pennypacker KR. Intracranial VCAM1 at time of mechanical thrombectomy predicts ischemic stroke severity. J Neuroinflammation 2021; 18:109. [PMID: 33971895 PMCID: PMC8111916 DOI: 10.1186/s12974-021-02157-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/23/2021] [Indexed: 02/07/2023] Open
Abstract
Background Emergent large vessel occlusion (ELVO) strokes are devastating ischemic vascular events for which novel treatment options are needed. Using vascular cell adhesion molecule 1 (VCAM1) as a prototype, the objective of this study was to identify proteomic biomarkers and network signaling functions that are potential therapeutic targets for adjuvant treatment for mechanical thrombectomy. Methods The blood and clot thrombectomy and collaboration (BACTRAC) study is a continually enrolling tissue bank and registry from stroke patients undergoing mechanical thrombectomy. Plasma proteins from intracranial (distal to clot) and systemic arterial blood (carotid) were analyzed by Olink Proteomics for N=42 subjects. Statistical analysis of plasma proteomics used independent sample t tests, correlations, linear regression, and robust regression models to determine network signaling and predictors of clinical outcomes. Data and network analyses were performed using IBM SPSS Statistics, SAS v 9.4, and STRING V11. Results Increased systemic (p<0.001) and intracranial (p=0.013) levels of VCAM1 were associated with the presence of hypertension. Intracranial VCAM1 was positively correlated to both infarct volume (p=0.032; r=0.34) and edema volume (p=0.026; r=0.35). The %∆ in NIHSS from admittance to discharge was found to be significantly correlated to both systemic (p=0.013; r = −0.409) and intracranial (p=0.011; r = −0.421) VCAM1 levels indicating elevated levels of systemic and intracranial VCAM1 are associated with reduced improvement of stroke severity based on NIHSS from admittance to discharge. STRING-generated analyses identified biologic functional descriptions as well as function-associated proteins from the predictive models of infarct and edema volume. Conclusions The current study provides novel data on systemic and intracranial VCAM1 in relation to stroke comorbidities, stroke severity, functional outcomes, and the role VCAM1 plays in complex protein-protein signaling pathways. These data will allow future studies to develop predictive biomarkers and proteomic targets for drug development to improve our ability to treat a devastating pathology. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-021-02157-4.
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Affiliation(s)
- Benton Maglinger
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - Madison Sands
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - Jacqueline A Frank
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA
| | | | - Amanda L Trout
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA
| | - Jill M Roberts
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, USA.,Department of Neurosurgery, University of Kentucky, Lexington, KY, USA
| | - Stephen Grupke
- Department of Neurosurgery and Neuroendovascular Surgery, Covenant Medical Center, Lubbock, TX, USA
| | - Jadwiga Turchan-Cholewo
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA
| | - Ann M Stowe
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, USA
| | - Justin F Fraser
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, USA.,Department of Neurosurgery, University of Kentucky, Lexington, KY, USA.,Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Keith R Pennypacker
- Department of Neurology, University of Kentucky, Lexington, KY, USA. .,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA. .,Department of Neuroscience, University of Kentucky, Lexington, KY, USA.
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6
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Tryggestad JB, Shah RD, Braffett BH, Bacha F, Gidding SS, Gubitosi-Klug RA, Shah AS, Urbina EM, Katz LEL. Circulating adhesion molecules and associations with HbA1c, hypertension, nephropathy, and retinopathy in the Treatment Options for type 2 Diabetes in Adolescent and Youth study. Pediatr Diabetes 2020; 21:923-931. [PMID: 32501612 PMCID: PMC7877547 DOI: 10.1111/pedi.13062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/30/2020] [Accepted: 05/28/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The Treatment Options for type 2 Diabetes in Adolescent and Youth study, a randomized clinical trial of three treatments for type 2 diabetes (T2DM) in youth, demonstrated treatment failure (defined as sustained HbA1c ≥8%, or inability to wean insulin after 3 months after acute metabolic decomposition) in over half of the participants. Given that binding of mononuclear cells to vascular endothelium, initiated by cellular adhesion molecules and chemokines, is an early step in vascular injury, we sought to evaluate (a) changes in cellular adhesion molecule levels during the trial; (b) effect of diabetes treatment; and (c) association of markers with HbA1c, hypertension, hypercholesterolemia, nephropathy, and retinopathy. METHODS Participants (n = 515 of 699) that had baseline assessment of adhesion molecules (monocyte chemoattractant protein-1 [MCP-1], vascular cell adhesion marker [VCAM], intercellular adhesion marker [ICAM], and E-Selectin) and at least one other assessment, measured at month 12, 24, or 36, were included. RESULTS Over 1 to 3 years, significant increases in MCP-1 and decreases in VCAM (both P < .0001) concentrations were found; however, no significant interactions were identified with treatment group for any molecule. For every 1% increase in HbA1c, ICAM increased by 1.8%, VCAM by 1.5%, and E-selectin by 6.8% (all P < .0001). E-selectin increased by 3.7% and 4.2% for every 10 mm Hg increase in systolic and diastolic blood pressure, respectively (both P < .0001). ICAM was 10.2% higher and E-selectin was 15.5% higher in participants with microalbuminuria (both P < .01). There was no significant association of adhesion molecule levels with retinopathy. CONCLUSION Concentrations of cellular adhesion molecules rise with increasing HbA1c in youth with T2DM, and are associated with blood pressure and microalbuminuria, markers of vascular injury.
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Affiliation(s)
- Jeanie B. Tryggestad
- Department of Diabetes and Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Rachana D. Shah
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Barbara H. Braffett
- The Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Fida Bacha
- Department of Diabetes and Endocrinology, Baylor College of Medicine, Houston, Texas, USA
| | | | - Rose A. Gubitosi-Klug
- Department of Pediatric Endocrinology, Diabetes and Metabolism, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amy S. Shah
- Division of Endocrinology, Cincinnati Children’s Hospital and the University of Cincinnati, Cincinnati, Ohio, USA
| | - Elaine M. Urbina
- Division of Endocrinology, Cincinnati Children’s Hospital and the University of Cincinnati, Cincinnati, Ohio, USA
| | - Lorraine E. Levitt Katz
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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GÜLER Ö, YILDIZ M, BOZDEMİR MN, KAVAKLI A, DAĞLI AF, ÜSTÜNDAĞ B. Deneysel Beyin İskemisinde Tacrolimusun Endotelin-1, Melatonin ve Heat Shock Protein-70 Üzerine Etkileri. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2019. [DOI: 10.17517/ksutfd.533419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Tanner C, Wang G, Liu N, Andrikopoulos S, Zajac JD, Ekinci EI. Metformin: time to review its role and safety in chronic kidney disease. Med J Aust 2019; 211:37-42. [PMID: 31187887 DOI: 10.5694/mja2.50239] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
■Metformin is recommended as first-line therapy for type 2 diabetes because of its safety, low cost and potential cardiovascular benefits. ■The use of metformin was previously restricted in people with chronic kidney disease (CKD) - a condition that commonly coexists with diabetes - due to concerns over drug accumulation and metformin-associated lactic acidosis. ■There are limited data from observational studies and small randomised controlled trials to suggest that metformin, independent of its antihyperglycaemic effects, may be associated with lower risk of myocardial infarction, stroke and all-cause mortality in people with type 2 diabetes and CKD. ■Research into the risk of metformin-associated lactic acidosis in CKD has previously been limited and conflicting, resulting in significant variation across international guidelines on the safe prescribing and dosing of metformin at different stages of renal impairment. ■Present-day large scale cohort studies now provide supporting evidence for the safe use of metformin in mild to moderate renal impairment (estimated glomerular filtration rate [eGFR] 30-60 mL/min/1.73m2 ). However, prescribing metformin in people with severe renal impairment (eGFR < 30 mL/min/1.73m2 ) remains a controversial issue. Due to observed increased risk of lactic acidosis and all-cause mortality in people with type 2 diabetes and severe renal impairment, it is generally recommended that metformin is discontinued if renal function falls below this level or during acute renal deterioration.
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Affiliation(s)
| | | | | | | | - Jeffrey D Zajac
- Austin Health, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Elif I Ekinci
- Austin Health, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
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Ramiro L, Simats A, García-Berrocoso T, Montaner J. Inflammatory molecules might become both biomarkers and therapeutic targets for stroke management. Ther Adv Neurol Disord 2018; 11:1756286418789340. [PMID: 30093920 PMCID: PMC6080077 DOI: 10.1177/1756286418789340] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/05/2018] [Indexed: 12/20/2022] Open
Abstract
Stroke is the fifth leading cause of death and the most frequent cause of disability worldwide. Currently, stroke diagnosis is based on neuroimaging; therefore, the lack of a rapid tool to diagnose stroke is still a major concern. In addition, therapeutic approaches to combat ischemic stroke are still scarce, since the only approved therapies are directed toward restoring blood flow to the affected brain area. However, due to the reduced time window during which these therapies are effective, few patients benefit from them; therefore, alternative treatments are urgently needed to reduce stroke brain damage in order to improve patients' outcome. The inflammatory response triggered after the ischemic event plays an important role in the progression of stroke; consequently, the study of inflammatory molecules in the acute phase of stroke has attracted increasing interest in recent decades. Here, we provide an overview of the inflammatory processes occurring during ischemic stroke, as well as the potential for these inflammatory molecules to become stroke biomarkers and the possibility that these candidates will become interesting neuroprotective therapeutic targets to be blocked or stimulated in order to modulate inflammation after stroke.
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Affiliation(s)
- Laura Ramiro
- Neurovascular Research Laboratory, Vall d’Hebron
Institute of Research, Universitat Autònoma de Barcelona, Barcelona,
Spain
| | - Alba Simats
- Neurovascular Research Laboratory, Vall d’Hebron
Institute of Research, Universitat Autònoma de Barcelona, Barcelona,
Spain
| | - Teresa García-Berrocoso
- Neurovascular Research Laboratory, Vall d’Hebron
Institute of Research, Universitat Autònoma de Barcelona, Barcelona,
Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d’Hebron
Institute of Research, Pg. Vall d’Hebron 119–129, Hospital Universitari Vall
d’Hebron, 08035 Barcelona, Spain
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10
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Grell AS, Mostajeran M, Edvinsson L, Ansar S. Contractile Responses in Spontaneously Hypertensive Rats after Transient Middle Cerebral Artery Occlusion. Pharmacology 2017; 101:120-132. [PMID: 29190633 DOI: 10.1159/000481570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 09/12/2017] [Indexed: 11/19/2022]
Abstract
Stroke is one of the leading causes of mortality and morbidity worldwide, and few therapeutic treatments have shown beneficial effect clinically. One reason for this could be the lack of risk factors incorporated into the preclinical stroke research. We have previously demonstrated phenotypic receptor changes to be one of the injurious mechanisms occurring after stroke but mostly in healthy rats. The aim of this study was to investigate if hypertension has an effect on vasoconstrictive receptor responses to endothelin 1, sarafotoxin 6c and angiotensin II after stroke by inducing transient middle cerebral artery occlusion in spontaneously hypertensive rats and Wistar-Kyoto rats using the wire-myograph. We demonstrated an increased contractile response to endothelin 1 and extracellular potassium as well as an increased carbachol-induced dilator response in the middle cerebral arteries from hypertensive rats after stroke. This study demonstrates the importance of including risk factors in experimental stroke research.
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Affiliation(s)
- Anne-Sofie Grell
- Department of Clinical Experimental Research, Glostrup Research Institute, Glostrup, Denmark
| | - Maryam Mostajeran
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Lars Edvinsson
- Department of Clinical Experimental Research, Glostrup Research Institute, Glostrup, Denmark.,Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Saema Ansar
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University, Lund, Sweden
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Kunutsor SK, Bakker SJL, Dullaart RPF. Soluble Vascular Cell Adhesion Molecules May be Protective of Future Cardiovascular Disease Risk: Findings from the PREVEND Prospective Cohort Study. J Atheroscler Thromb 2017; 24:804-818. [PMID: 28202840 PMCID: PMC5556188 DOI: 10.5551/jat.38836] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Aim: Soluble cell adhesion molecules, such as vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1, E-selectin, and P-selectin, have been suggested to be associated with cardiovascular disease (CVD) risk; however, the nature and magnitude of the association between VCAM-1 and CVD risk is uncertain. We aimed to assess the association of VCAM-1 with CVD risk and determine its potential utility for CVD risk prediction. Methods: VCAM-1 concentrations were measured at baseline in the PREVEND prospective study of 2,638 participants. Hazard ratios (95% confidence intervals [CI]) and measures of risk discrimination for CVD (e.g., C-index) and reclassification (i.e., net reclassification improvement) of participants were assessed. Results: During a median follow-up of 9.9 years, 614 CVD events occurred. Plasma VCAM-1 was weakly associated with several cardiovascular risk markers. In analyses adjusted for established cardiovascular risk factors, the hazard ratio (95% CI) for CVD per 1 standard deviation increase in loge VCAM-1 was 0.91 (0.84–0.99; P = 0.020), which remained consistent after additional adjustment for body mass index, alcohol consumption, triglycerides, renal function, and C-reactive protein; hazard ratio (95% CI) 0.89 (0.82–0.97; P = 0.006). Comparing the top versus bottom quintiles of VCAM-1 levels, the corresponding adjusted hazard ratios were 0.74 (0.57–0.96; P = 0.023) and 0.70 (0.54–0.91; P = 0.007) respectively. Adding VCAM-1 to a CVD risk prediction model containing conventional risk factors did not improve the C-index or net reclassification. Conclusions: Plasma VCAM-1 is inversely and independently associated with CVD. However, VCAM-1 provides no significant improvement in CVD risk assessment beyond conventional CVD risk factors.
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Affiliation(s)
| | - Stephan J L Bakker
- Department of Nephrology Medicine, University of Groningen and University Medical Center Groningen.,Top Institute Food and Nutrition
| | - Robin P F Dullaart
- Department of Endocrinology, University of Groningen and University Medical Center Groningen
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Simats A, García-Berrocoso T, Montaner J. Neuroinflammatory biomarkers: From stroke diagnosis and prognosis to therapy. Biochim Biophys Acta Mol Basis Dis 2015; 1862:411-24. [PMID: 26524637 DOI: 10.1016/j.bbadis.2015.10.025] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/19/2015] [Accepted: 10/28/2015] [Indexed: 12/29/2022]
Abstract
Stroke is the third leading cause of death in industrialized countries and one of the largest causes of permanent disability worldwide. Therapeutic options to fight stroke are still limited and the only approved drug is tissue-plasminogen activator (tPA) and/or mechanical thrombectomy. Post-stroke inflammation is well known to contribute to the expansion of the ischemic lesion, whereas its resolution stimulates tissue repair and neuroregeneration processes. As inflammation highly influences susceptibility of stroke patients to overcome the disease, there is an increasing need to develop new diagnostic, prognostic and therapeutic strategies for post-stroke inflammation. This review provides a brief overview of the contribution of the inflammatory mechanisms to the pathophysiology of stroke. It specially focuses on the role of inflammatory biomarkers to help predicting stroke patients' outcome since some of those biomarkers might turn out to be targets to be therapeutically altered overcoming the urgent need for the identification of potent drugs to modulate stroke-associated inflammation. This article is part of a Special Issue entitled: Neuro Inflammation edited by Helga E. de Vries and Markus Schwaninger.
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Affiliation(s)
- Alba Simats
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain.
| | - Teresa García-Berrocoso
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain.
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain; Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain.
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Zhang H, Sachdev PS, Wen W, Crawford JD, Brodaty H, Baune BT, Kochan NA, Slavin MJ, Reppermund S, Kang K, Trollor JN. The relationship between inflammatory markers and voxel-based gray matter volumes in nondemented older adults. Neurobiol Aging 2015; 37:138-146. [PMID: 26559883 DOI: 10.1016/j.neurobiolaging.2015.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/24/2015] [Accepted: 10/08/2015] [Indexed: 11/26/2022]
Abstract
Ageing is characterized by chronically elevated inflammatory markers (IMs). Peripheral IM levels have been found in negative correlations with brain structural measures including global and lobar volumes and the hippocampus. This study investigated the relationship between 10 peripheral IMs and voxel-based gray matter (GM) volumes in nondemented older adults (n = 463). Two proinflammatory cytokines (tumor necrosis factor-α [TNF-α] and interleukin-1β) and 2 vascular IMs (vascular cellular adhesion molecule-1 and plasminogen activator inhibitor-1) were negatively correlated with regional GM volumes. TNF-α and interleukin-1β were both significantly correlated with GM volumes in the left occipitotemporal area, left superior occipital gyrus, and left inferior parietal lobule; TNF-α was also significantly correlated with the bilateral medial prefrontal cortices and approached significance for the correlations with the bilateral hippocampi. Significant GM correlations with vascular cellular adhesion molecule-1 were located in the bilateral anterior cingulate cortices, and with plasminogen activator inhibitor-1 in the cerebellum and right hippocampus. The neuroanatomical correlation patterns of 2 proinflammatory cytokines and 2 vascular IMs might be reflective of the effects of neurodegenerative and vascular pathological processes in the ageing brain.
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Affiliation(s)
- Haobo Zhang
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Perminder S Sachdev
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia; Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Wei Wen
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia; Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - John D Crawford
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Henry Brodaty
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia; Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Randwick, New South Wales, Australia; Dementia Collaborative Research Centre, School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Bernard T Baune
- Department of Psychiatry, University of Adelaide, Adelaide, South Australia, Australia
| | - Nicole A Kochan
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia; Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Melissa J Slavin
- Dementia Collaborative Research Centre, School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Simone Reppermund
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia; Department of Developmental Disability Neuropsychiatry, School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Kristan Kang
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Julian N Trollor
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia; Department of Developmental Disability Neuropsychiatry, School of Psychiatry, University of New South Wales, Sydney, Australia.
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Giannopoulos S, Kosmidou M, Hatzitolios AI, Savopoulos CG, Ziakas A, Karamouzis M. Measurements of endothelin-1, C-reactive protein and fibrinogen plasma levels in patients with acute ischemic stroke. Neurol Res 2013; 30:727-30. [DOI: 10.1179/174313208x297904] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Zhu N, Li H, Han M, Guo L, Chen L, Yun Y, Guo Z, Li G, Sang N. Environmental nitrogen dioxide (NO2) exposure influences development and progression of ischemic stroke. Toxicol Lett 2012; 214:120-30. [DOI: 10.1016/j.toxlet.2012.08.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 08/21/2012] [Accepted: 08/22/2012] [Indexed: 10/27/2022]
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Martínez-Revelles S, Caracuel L, Márquez-Martín A, Dantas A, Oliver E, D'Ocon P, Vila E. Increased endothelin-1 vasoconstriction in mesenteric resistance arteries after superior mesenteric ischaemia-reperfusion. Br J Pharmacol 2012; 165:937-50. [PMID: 21806604 PMCID: PMC3312490 DOI: 10.1111/j.1476-5381.2011.01617.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 07/05/2011] [Accepted: 07/12/2011] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Endothelin-1 (ET-1) plays an important role in the maintenance of vascular tone. We aimed to evaluate the influence of superior mesenteric artery (SMA) ischaemia-reperfusion (I/R) on mesenteric resistance artery vasomotor function and the mechanism involved in the changes in vascular responses to ET-1. EXPERIMENTAL APPROACH SMA from male Sprague-Dawley rats was occluded (90 min) and following reperfusion (24h), mesenteric resistance arteries were dissected. Vascular reactivity was studied using wire myography. Protein and mRNA expression, superoxide anion (O(2) (•-) ) production and ET-1 plasma concentration were evaluated by immunofluorescence, real-time quantitative PCR, ethidium fluorescence and elisa, respectively. KEY RESULTS I/R increased ET-1 plasma concentration, ET-1-mediated vasoconstriction and ET(B) mRNA expression, and down-regulated ET(A) mRNA expression. Immunofluorescence confirmed mRNA results and revealed an increase in ET(B) receptors in the mesenteric resistance artery media layer after I/R. Therefore, the ET(B) receptor agonist sarafotoxin-6 induced a contraction that was inhibited by the ET(B) receptor antagonist BQ788 only in vessels, with and without endothelium, from I/R rats. Furthermore, BQ788 potentiated ET-1 vasoconstriction only in sham rats. Endothelium removal in rings from I/R rats unmasked the inhibition of ET-1 vasoconstriction by BQ788. Endothelium removal, N(ω) -nitro-L-arginine methyl ester and superoxide dismutase abolished the differences in ET-1 vasoconstriction between sham and I/R rats. We also found that I/R down-regulates endothelial NOS mRNA expression and concomitantly enhanced O(2) (•-) production by increasing NADPH oxidase 1 (NOX-1) and p(47phox) mRNA. CONCLUSIONS AND IMPLICATIONS Mesenteric I/R potentiated the ET-1-mediated vasoconstriction by a mechanism that involves up-regulation of muscular ET(B) receptors and decrease in NO bioavailability.
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Affiliation(s)
- S Martínez-Revelles
- Departament de Farmacologia, Terapèutica i Toxicologia, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
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Sang N, Yun Y, Li H, Hou L, Han M, Li G. SO2 Inhalation Contributes to the Development and Progression of Ischemic Stroke in the Brain. Toxicol Sci 2010; 114:226-36. [DOI: 10.1093/toxsci/kfq010] [Citation(s) in RCA: 230] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Moldes O, Sobrino T, Millán M, Castellanos M, Pérez de la Ossa N, Leira R, Serena J, Vivancos J, Dávalos A, Castillo J. High Serum Levels of Endothelin-1 Predict Severe Cerebral Edema in Patients With Acute Ischemic Stroke Treated With t-PA. Stroke 2008; 39:2006-10. [DOI: 10.1161/strokeaha.107.495044] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Octavio Moldes
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
| | - Tomás Sobrino
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
| | - Mónica Millán
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
| | - Mar Castellanos
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
| | - Natalia Pérez de la Ossa
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
| | - Rogelio Leira
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
| | - Joaquín Serena
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
| | - José Vivancos
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
| | - Antonio Dávalos
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
| | - José Castillo
- From the Department of Neurology (O.M., T.S., R.L., J.C.), Clinical Neuroscience Research Laboratory, Hospital Clínico Universitario, University of Santiago de Compostela, Santiago de Compostela; the Department of Neurosciences (M.M., N.P.d.l.O., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; the Department of Neurology (M.C., J.S.), Hospital Universitari Doctor Josep Trueta, Girona; and the Department of Neurology (J.V.), Hospital Universitario de La Princesa, Madrid, Spain
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