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Schneider AM, Regenhardt RW, Dmytriw AA, Patel AB, Hirsch JA, Buchan AM. Cerebroprotection in the endovascular era: an update. J Neurol Neurosurg Psychiatry 2023; 94:267-271. [PMID: 36600581 DOI: 10.1136/jnnp-2022-330379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/19/2022] [Indexed: 12/12/2022]
Abstract
Despite advances in clinical diagnosis and increasing numbers of patients eligible for revascularisation, ischaemic stroke remains a significant public health concern accounting for 3.3 million deaths annually. In addition to recanalisation therapy, patient outcomes could be improved through cerebroprotection, but all translational attempts have remained unsuccessful. In this narrative review, we discuss potential reasons for those failures. We then outline the diverse, multicellular effects of ischaemic stroke and the complex temporal sequences of the pathophysiological cascade during and following ischaemia, reperfusion, and recovery. This evidence is linked with findings from prior cerebroprotective trials and interpreted for the modern endovascular era. Future cerebroprotective agents that are multimodal and multicellular, promoting cellular and metabolic health to different targets at time points that are most responsive to treatment, might prove more successful.
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Affiliation(s)
- Anna M Schneider
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua Adam Hirsch
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alastair M Buchan
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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Maglinger B, Frank JA, Fraser JF, Pennypacker KR. Reverse Translation to Develop Post-stroke Therapeutic Interventions during Mechanical Thrombectomy: Lessons from the BACTRAC Trial. Methods Mol Biol 2023; 2616:391-402. [PMID: 36715948 DOI: 10.1007/978-1-0716-2926-0_27] [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] [Indexed: 01/31/2023]
Abstract
The majority of strokes, approximately 87%, are ischemic in etiology with the remaining hemorrhagic in origin. Emergent large vessel occlusions (ELVOs) are a subtype of ischemic stroke accounting for approximately 30-40% of acute large vessel blockages. Treatment for ELVOs focuses on recanalization of the occluded vessel by time-sensitive administration of tissue plasminogen activator (tPA) or thrombus removal using mechanical thrombectomy. Although a great deal of time and resources have focused on translational stroke research, little progress has been made in the area of identifying additional new treatments for stroke. Translational limitations include difficulty simulating human comorbid conditions in animal models, as well as the temporal nature of stroke pathology. The Blood And Clot Thrombectomy Registry And Collaboration represents an ongoing tissue registry for thrombectomy patients and includes collection of intracranial arterial blood, systemic arterial blood, thrombi, as well as a series of clinical and radiographic data points for analysis. This chapter will explore the methodologies employed and results obtained from studying BACTRAC-derived human biological specimens and how they can inform translational experimental design in animal studies.
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Affiliation(s)
- Benton Maglinger
- Department of Neurology, Department of Neuroscience, The University of Kentucky, Lexington, KY, USA
| | - Jacqueline A Frank
- Department of Neurology, Department of Neuroscience, The University of Kentucky, Lexington, KY, USA
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA
| | - Justin F Fraser
- Department of Neurology, Department of Neuroscience, The University of Kentucky, Lexington, KY, USA
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA
- Department of Neurosurgery, University of Kentucky, Lexington, KY, USA
- Department of Radiology, University of Kentucky, Lexington, KY, USA
- Department of Neuroscience, University of Kentucky, Lexington, KY, USA
| | - Keith R Pennypacker
- Department of Neurology, Department of Neuroscience, The University of Kentucky, Lexington, KY, USA.
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA.
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3
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Maniskas ME, Roberts JM, Gorman A, Bix GJ, Fraser JF. Intra-arterial combination therapy for experimental acute ischemic stroke. Clin Transl Sci 2021; 15:279-286. [PMID: 34463026 PMCID: PMC8742650 DOI: 10.1111/cts.13147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/14/2021] [Accepted: 08/06/2021] [Indexed: 11/28/2022] Open
Abstract
Acute ischemic stroke continues to devastate millions of individuals worldwide. Current treatments work to restore blood flow but not rescue affected tissue. Our goal was to develop a combination of neuroprotective agents administered intra-arterially following recanalization to target ischemic tissue. Using C57Bl/6J male mice, we performed tandem transient ipsilateral middle cerebral/common carotid artery occlusion, followed by immediate intra-arterial pharmacotherapy administration through a standardized protocol. Two pharmacotherapy agents, verapamil and lubeluzole, were selected based on their potential to modulate different aspects of the ischemic cascade; verapamil, a calcium channel blocker, works in an acute fashion blocking L-type calcium channels, whereas lubeluzole, an N-methyl-D-aspartate modulator, works in a delayed fashion blocking intracellular glutamate trafficking. We hypothesized that combination therapy would provide complimentary and potentially synergistic benefit treating brain tissue undergoing various stages of injury. Physiological measurements for heart rate and pulse distention (blood pressure) demonstrated no detrimental effects between groups, suggesting that the combination drug administration is safe. Tissue analysis demonstrated a significant difference between combination and control (saline) groups in infarct volume, neuronal health, and astrogliosis. Although a significant difference in functional outcome was not observed, we did note that the combination treatment group had a greater percent change from baseline in forced motor movement as compared with controls. This study demonstrates the safety and feasibility of intra-arterial combination therapy following successful recanalization and warrants further study.
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Affiliation(s)
- Michael E Maniskas
- Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA.,Department of Neurology, University of Kentucky, Lexington, Kentucky, USA.,Department of Radiology, University of Kentucky, Lexington, Kentucky, USA.,Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA.,Sanders Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA
| | - Jill M Roberts
- Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA.,Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
| | - Amanda Gorman
- Sanders Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA
| | - Gregory J Bix
- Clinical Neuroscience Research Center, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Justin F Fraser
- Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA.,Department of Neurology, University of Kentucky, Lexington, Kentucky, USA.,Department of Radiology, University of Kentucky, Lexington, Kentucky, USA.,Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA
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4
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Extended Middle Cerebral Artery Occlusion (MCAO) Model to Mirror Stroke Patients Undergoing Thrombectomy. Transl Stroke Res 2021; 13:604-615. [PMID: 34398389 PMCID: PMC8847541 DOI: 10.1007/s12975-021-00936-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
Stroke remains a leading global cause of death and disability. In the last decade, the therapeutic window for mechanical thrombectomy has increased from a maximum of 6 to 24 h and beyond. While endovascular advancements have improved rates of recanalization, no post-stroke pharmacotherapeutics have been effective in enhancing neurorepair and recovery. New experimental models are needed to closer mimic the human patient. Our group has developed a model of transient 5-h occlusion in rats to mimic stroke patients undergoing thrombectomy. Our procedure was designed specifically in aged rats and was optimized based on sex in order to keep mortality and extent of injury consistent between aged male and female rats. This model uses a neurological assessment modeled after the NIH Stroke Scale. Finally, the potential for translation between our rat model of stroke and humans was assessed using comparative gene expression for key inflammatory genes. This model will be useful in the evaluation of therapeutic targets to develop adjuvant treatments for large vessel occlusion during the thrombectomy procedure.
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5
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Messmer SJ, Fraser JF, Pennypacker KR, Roberts JM. Method of intra-arterial drug administration in a rat: Sex based optimization of infusion rate. J Neurosci Methods 2021; 357:109178. [PMID: 33819555 DOI: 10.1016/j.jneumeth.2021.109178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/26/2021] [Accepted: 03/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endovascular thrombectomy is the process of removing a blood clot and re-establishing blood flow in patients with emergent large vessel occlusion. The technique provides an opportunity to deliver therapeutics directly to the site of injury. The intra-arterial (IA) route of drug administration in the mouse was developed to bridge the gap between animal stroke treatments and clinical stroke therapy. Here, we adapted the IA method for use in rats, by investigating various flow rates to optimize the IA injection through the internal carotid artery (ICA). METHODS Male and female Sprague-Dawley rats (∼4 months of age) were subjected to placement of micro-angio tubing at the bifurcation of the common carotid artery for injection into the ICA. We evaluated a range of infusion rates of carbon black ink and its vascular distribution within the brain. RESULTS Optimal injection rates in males was 4-6 μl/min and 2-4 μl/min in females. The IA injection using these sex-specific rates resulted in appropriate limited dye delivery to only the ipsilateral region of the brain, without inducing a subarachnoid hemorrhage. CONCLUSION Upon adapting the IA administration model to rats, it was determined that the rate of infusion varied between males and females. This variability is an important consideration for studies utilizing both sexes, such as in ischemic stroke studies.
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Affiliation(s)
- Sarah J Messmer
- Center for Advanced Translational Stroke Science, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA; Department of Neurology, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA
| | - Justin F Fraser
- Center for Advanced Translational Stroke Science, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA; Department of Neurology, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA; Department of Neurosurgery, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA; Department of Neuroscience, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA; Department of Radiology, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA
| | - Keith R Pennypacker
- Center for Advanced Translational Stroke Science, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA; Department of Neurology, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA; Department of Neuroscience, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA
| | - Jill M Roberts
- Center for Advanced Translational Stroke Science, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA; Department of Neurosurgery, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA; Department of Neuroscience, University of Kentucky, 741 S. Limestone, Lexington, KY 40536, USA.
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Danegaptide Enhances Astrocyte Gap Junctional Coupling and Reduces Ischemic Reperfusion Brain Injury in Mice. Biomolecules 2020; 10:biom10030353. [PMID: 32110860 PMCID: PMC7175267 DOI: 10.3390/biom10030353] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 12/19/2022] Open
Abstract
Ischemic stroke is a complex and devastating event characterized by cell death resulting from a transient or permanent arterial occlusion. Astrocytic connexin43 (Cx43) gap junction (GJ) proteins have been reported to impact neuronal survival in ischemic conditions. Consequently, Cx43 could be a potential target for therapeutic approaches to stroke. We examined the effect of danegaptide (ZP1609), an antiarrhythmic dipeptide that specifically enhances GJ conductance, in two different rodent stroke models. In this study, danegaptide increased astrocytic Cx43 coupling with no significant effects on Cx43 hemichannel activity, in vitro. Using matrix-assisted laser desorption ionization imaging mass spectrometry (MALDI IMS) the presence of danegaptide within brain tissue sections were detected one hour after reperfusion indicating successful transport of the dipeptide across the blood brain barrier. Furthermore, administration of danegaptide in a novel mouse brain ischemia/reperfusion model showed significant decrease in infarct volume. Taken together, this study provides evidence for the therapeutic potential of danegaptide in ischemia/reperfusion stroke.
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7
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Salmeron KE, Maniskas ME, Edwards DN, Wong R, Rajkovic I, Trout A, Rahman AA, Hamilton S, Fraser JF, Pinteaux E, Bix GJ. Interleukin 1 alpha administration is neuroprotective and neuro-restorative following experimental ischemic stroke. J Neuroinflammation 2019; 16:222. [PMID: 31727174 PMCID: PMC6857151 DOI: 10.1186/s12974-019-1599-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 09/24/2019] [Indexed: 01/06/2023] Open
Abstract
Background Stroke remains a leading cause of death and disability worldwide despite recent treatment breakthroughs. A primary event in stroke pathogenesis is the development of a potent and deleterious local and peripheral inflammatory response regulated by the pro-inflammatory cytokine interleukin-1 (IL-1). While the role of IL-1β (main released isoform) has been well studied in stroke, the role of the IL-1α isoform remains largely unknown. With increasing utilization of intravenous tissue plasminogen activator (t-PA) or thrombectomy to pharmacologically or mechanically remove ischemic stroke causing blood clots, respectively, there is interest in pairing successful cerebrovascular recanalization with neurotherapeutic pharmacological interventions (Fraser et al., J Cereb Blood Flow Metab 37:3531–3543, 2017; Hill et al., Lancet Neurol 11:942–950, 2012; Amaro et al., Stroke 47:2874–2876, 2016). Methods Transient stroke was induced in mice via one of two methods. One group of mice were subjected to tandem ipsilateral common carotid artery and middle cerebral artery occlusion, while another group underwent the filament-based middle cerebral artery occlusion. We have recently developed an animal model of intra-arterial (IA) drug administration after recanalization (Maniskas et al., J Neurosci Met 240:22–27, 2015). Sub groups of the mice were treated with either saline or Il-1α, wherein the drug was administered either acutely (immediately after surgery) or subacutely (on the third day after stroke). This was followed by behavioral and histological analyses. Results We now show in the above-mentioned mouse stroke models (transient tandem ipsilateral common carotid artery (CCA) and middle cerebral artery occlusion (MCA) occlusion, MCA suture occlusion) that IL-1α is neuroprotective when acutely given either intravenously (IV) or IA at low sub-pathologic doses. Furthermore, while IV administration induces transient hemodynamic side effects without affecting systemic markers of inflammation, IA delivery further improves overall outcomes while eliminating these side effects. Additionally, we show that delayed/subacute IV IL-1α administration ameliorates functional deficit and promotes neurorepair. Conclusions Taken together, our present study suggests for the first time that IL-1α could, unexpectedly, be an effective ischemic stroke therapy with a broad therapeutic window.
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Affiliation(s)
- Kathleen E Salmeron
- Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, 40536, USA
| | - Michael E Maniskas
- Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neurosurgery, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neurology, University of Texas Health Science Center, Houston, TX, 77030, USA
| | - Danielle N Edwards
- Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, 40536, USA
| | - Raymond Wong
- Faculty of Biology, Medicine and Health, A.V. Hill Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Ivana Rajkovic
- Faculty of Biology, Medicine and Health, A.V. Hill Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Amanda Trout
- Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neurology, University of Kentucky, Lexington, KY, 40536, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA
| | - Abir A Rahman
- Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, 40536, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA
| | - Samantha Hamilton
- Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, 40536, USA
| | - Justin F Fraser
- Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neurosurgery, University of Kentucky, Lexington, KY, 40536, USA.,Department of Neurology, University of Kentucky, Lexington, KY, 40536, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA
| | - Emmanuel Pinteaux
- Faculty of Biology, Medicine and Health, A.V. Hill Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | - Gregory J Bix
- Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, 40536, USA. .,Department of Neuroscience, University of Kentucky, Lexington, KY, 40536, USA. .,Department of Neurosurgery, University of Kentucky, Lexington, KY, 40536, USA. .,Department of Neurology, University of Kentucky, Lexington, KY, 40536, USA. .,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, 40536, USA.
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8
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Wang JSH, Freitas-Andrade M, Bechberger JF, Naus CC, Yeung KKC, Whitehead SN. Matrix-assisted laser desorption/ionization imaging mass spectrometry of intraperitoneally injected danegaptide (ZP1609) for treatment of stroke-reperfusion injury in mice. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2018; 32:951-958. [PMID: 29575411 DOI: 10.1002/rcm.8115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 06/08/2023]
Abstract
RATIONALE This work focuses on direct matrix-assisted laser desorption/ionization imaging mass spectrometry (MALDI-IMS) detection of intraperitoneally (IP)-injected dipeptide ZP1609 in mouse brain tissue. Direct analysis of drug detection in intact tissue sections provides distribution information that can impact drug development. MALDI-IMS capabilities of uncovering drug transport across the blood-brain barrier are demonstrated. METHODS Successful peptide detection using MALDI-IMS was achieved using a MALDI TOF/TOF system. Upon optimization of sample preparation procedures for dipeptide ZP1609, an additional tissue acidification procedure was found to greatly enhance signal detection. The imaging data acquired was able to determine successful transport of ZP1609 across the blood-brain barrier. Data obtained from MALDI-IMS can help shape our understanding of biological functions, disease progression, and effects of drug delivery. RESULTS Direct detection of ZP1609 throughout the brain tissue sections was observed from MALDI-MS images. However, in cases where there was induction of stroke, a peak of lower signal intensity was also detected in the target m/z region. Although distinct differences in signal intensity can be seen between control and experimental groups, fragments and adducts of ZP1609 were investigated using MALDI-IMS to verify detection of the target analyte. CONCLUSIONS Overall, the data reveals successful penetration of ZP1609 across the blood-brain barrier. The benefits of tissue acidification in the enhancement of detection sensitivity for low-abundance peptides were demonstrated. MALDI-IMS has been shown to be a useful technique in the direct detection of drugs within intact brain tissue sections.
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Affiliation(s)
- Jasmine S H Wang
- Department of Chemistry and Department of Biochemistry, University of Western Ontario, London, ON, Canada, N6A 5B7 and N6A 5C1
- Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology, University of Western Ontario, London, ON, Canada, N6A 5C1
| | - Moises Freitas-Andrade
- Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, BC, Canada, V6T 1Z3
| | - John F Bechberger
- Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, BC, Canada, V6T 1Z3
| | - Christian C Naus
- Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, BC, Canada, V6T 1Z3
| | - Ken K-C Yeung
- Department of Chemistry and Department of Biochemistry, University of Western Ontario, London, ON, Canada, N6A 5B7 and N6A 5C1
| | - Shawn N Whitehead
- Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology, University of Western Ontario, London, ON, Canada, N6A 5C1
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Fraser JF, Maniskas M, Trout A, Lukins D, Parker L, Stafford WL, Alhajeri A, Roberts J, Bix GJ. Intra-arterial verapamil post-thrombectomy is feasible, safe, and neuroprotective in stroke. J Cereb Blood Flow Metab 2017; 37:3531-3543. [PMID: 28429604 PMCID: PMC5669346 DOI: 10.1177/0271678x17705259] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Large vessel ischemic stroke represents the most disabling subtype. While t-PA and endovascular thrombectomy can recanalize the occluded vessel, good clinical outcomes are not uniformly achieved. We propose that supplementing endovascular thrombectomy with superselective intra-arterial (IA) verapamil immediately following recanalization could be safe and effective. Verapamil, a calcium channel blocker, has been shown to be an effective IA adjunct in a pre-clinical mouse focal ischemia model. To demonstrate translational efficacy, mechanism, feasibility, and safety, we conducted a group of translational experiments. We performed in vivo IA dose-response evaluation in our animal stroke model with C57/Bl6 mice. We evaluated neuroprotective mechanism through in vitro primary cortical neuron (PCN) cultures. Finally, we performed a Phase I trial, SAVER-I, to evaluate feasibility and safety of administration in the human condition. IA verapamil has a likely plateau or inverted-U dose-response with a defined toxicity level in mice (LD50 16-17.5 mg/kg). Verapamil significantly prevented PCN death and deleterious ischemic effects. Finally, the SAVER-I clinical trial showed no evidence that IA verapamil increased the risk of intracranial hemorrhage or other adverse effect/procedural complication in human subjects. We conclude that superselective IA verapamil administration immediately following thrombectomy is safe and feasible, and has direct, dose-response-related benefits in ischemia.
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Affiliation(s)
- Justin F Fraser
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,2 Department of Neurology, University of Kentucky, Lexington, KY, USA.,3 Department of Radiology, University of Kentucky, Lexington, KY, USA.,4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA
| | - Michael Maniskas
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA
| | - Amanda Trout
- 4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA
| | - Doug Lukins
- 3 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Lindsey Parker
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA
| | - W Lane Stafford
- 3 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Abdulnasser Alhajeri
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,2 Department of Neurology, University of Kentucky, Lexington, KY, USA.,3 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Jill Roberts
- 4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA.,5 Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, USA
| | - Gregory J Bix
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,2 Department of Neurology, University of Kentucky, Lexington, KY, USA.,4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA.,5 Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, USA
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10
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Maniskas ME, Roberts JM, Trueman R, Learoyd AE, Gorman A, Fraser JF, Bix GJ. Intra-arterial nitroglycerin as directed acute treatment in experimental ischemic stroke. J Neurointerv Surg 2016; 10:29-33. [PMID: 28031354 DOI: 10.1136/neurintsurg-2016-012793] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/07/2016] [Accepted: 12/09/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Nitroglycerin (also known as glyceryl trinitrate (GTN)), a vasodilator best known for treatment of ischemic heart disease, has also been investigated for its potential therapeutic benefit in ischemic stroke. The completed Efficacy of Nitric Oxide in Stroke trial suggested that GTN has therapeutic benefit with acute (within 6 hours) transdermal systemic sustained release therapy. OBJECTIVE To examine an alternative use of GTN as an acute therapy for ischemic stroke following successful recanalization. METHODS We administered GTN IA following transient middle cerebral artery occlusion in mice. Because no standard dose of GTN is available following emergent large vessel occlusion, we performed a dose-response (3.12, 6.25, 12.5, and 25 µg/µL) analysis. Next, we looked at blood perfusion (flow) through the middle cerebral artery using laser Doppler flowmetry. Functional outcomes, including forced motor movement rotor rod, were assessed in the 3.12, 6.25, and 12.5 µg/µL groups. Histological analysis was performed using cresyl violet for infarct volume, and glial fibrillary activating protein (GFAP) and NeuN immunohistochemistry for astrocyte activation and mature neuron survival, respectively. RESULTS Overall, we found that acute post-stroke IA GTN had little effect on vessel dilatation after 15 min. Functional analysis showed a significant difference between GTN (3.12 and 6.25 µg/µL) and control at post-stroke day 1. Histological measures showed a significant reduction in infarct volume and GFAP immunoreactivity and a significant increase in NeuN. CONCLUSIONS These results demonstrate that acute IA GTN is neuroprotective in experimental ischemic stroke and warrants further study as a potentially new stroke therapy.
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Affiliation(s)
- Michael E Maniskas
- Department of Anatomy & Neurobiology, University of Kentucky, Lexington, Kentucky, USA.,Sanders Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA.,Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA
| | - Jill M Roberts
- Department of Anatomy & Neurobiology, University of Kentucky, Lexington, Kentucky, USA.,Sanders Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA
| | - Rebecca Trueman
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | | | - Amanda Gorman
- Sanders Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA
| | - Justin F Fraser
- Department of Anatomy & Neurobiology, University of Kentucky, Lexington, Kentucky, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA.,Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA.,Department of Neurology, University of Kentucky, Lexington, Kentucky, USA.,Department of Radiology, University of Kentucky, Lexington, Kentucky, USA
| | - Gregory J Bix
- Department of Anatomy & Neurobiology, University of Kentucky, Lexington, Kentucky, USA.,Sanders Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA.,Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA.,Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA.,Department of Neurology, University of Kentucky, Lexington, Kentucky, USA
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11
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Maniskas ME, Roberts JM, Aron I, Fraser JF, Bix GJ. Stroke neuroprotection revisited: Intra-arterial verapamil is profoundly neuroprotective in experimental acute ischemic stroke. J Cereb Blood Flow Metab 2016; 36:721-30. [PMID: 26661189 PMCID: PMC4821022 DOI: 10.1177/0271678x15608395] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 07/21/2015] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Michael E Maniskas
- Department of Anatomy and Neurobiology, University of Kentucky, Lexington, USA Sanders Brown Center on Aging, University of Kentucky, Lexington, USA
| | - Jill M Roberts
- Department of Anatomy and Neurobiology, University of Kentucky, Lexington, USA Sanders Brown Center on Aging, University of Kentucky, Lexington, USA
| | - Ishi Aron
- Sanders Brown Center on Aging, University of Kentucky, Lexington, USA
| | - Justin F Fraser
- Department of Anatomy and Neurobiology, University of Kentucky, Lexington, USA Department of Neurosurgery, University of Kentucky, Lexington, USA Department of Neurology, University of Kentucky, Lexington, Kentucky Department of Radiology, University of Kentucky, Lexington, USA
| | - Gregory J Bix
- Department of Anatomy and Neurobiology, University of Kentucky, Lexington, USA Sanders Brown Center on Aging, University of Kentucky, Lexington, USA Department of Neurology, University of Kentucky, Lexington, Kentucky
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