Tirilazad treatment does not decrease early brain injury after transient focal ischemia in cats

Targeting Parthanatos in Ischemic Stroke

Parthanatos is a cell death signaling pathway in which excessive oxidative damage to DNA leads to over-activation of poly(ADP-ribose) polymerase (PARP). PARP then generates the formation of large poly(ADP-ribose) polymers that induce the release of apoptosis-inducing factor from the outer mitochondrial membrane. In the cytosol, apoptosis-inducing factor forms a complex with macrophage migration inhibitory factor that translocates into the nucleus where it degrades DNA and produces cell death. In a review of the literature, we identified 24 publications from 13 laboratories that support a role for parthanatos in young male mice and rats subjected to transient and permanent middle cerebral artery occlusion (MCAO). Investigators base their conclusions on the use of nine different PARP inhibitors (19 studies) or PARP1-null mice (7 studies). Several studies indicate a therapeutic window of 4-6 h after MCAO. In young female rats, two studies using two different PARP inhibitors from two labs support a role for parthanatos, whereas two studies from one lab do not support a role in young female PARP1-null mice. In addition to parthanatos, a body of literature indicates that PARP inhibitors can reduce neuroinflammation by interfering with NF-κB transcription, suppressing matrix metaloproteinase-9 release, and limiting blood-brain barrier damage and hemorrhagic transformation. Overall, most of the literature strongly supports the scientific premise that a PARP inhibitor is neuroprotective, even when most did not report behavior outcomes or address the issue of randomization and treatment concealment. Several third-generation PARP inhibitors entered clinical oncology trials without major adverse effects and could be repurposed for stroke. Evaluation in aged animals or animals with comorbidities will be important before moving into clinical stroke trials.

Review : Neuroprotection in Brain Ischemia: An Update (Part II

Ischemic brain injury produced by stroke or cardiac arrest is a major cause of human neurological disability. Steady advances in the neurosciences have elucidated the pathophysiological mechanisms of brain ischemia and have suggested many therapeutic approaches to achieve neuroprotection of the acutely ischemic brain that are directed at specific injury mechanisms. In the second portion of this two-part review, the following potential therapeutic approaches to acute ischemic injury are considered: 1) modulation of nonglutamatergic neurotransmission, including monoaminergic systems (dopamine, norepinephrine, serotonin), γ-aminobutyric acid, and adenosine; 2) mild-to-moderate therapeutic hypothermia; 3) calcium channel antagonism; 4) an tagonism of oxygen free radicals; 5) modulation of the nitric oxide system; 6) antagonism of cytoskeletal proteolysis; 7) growth factor administration; 8) therapy directed at cellular mediators of injury; and 9) the rationale for combination pharmacotherapy. The Neuroscientist 1:164-175, 1995

The role of free radical generation in increasing cerebrovascular permeability

The brain endothelium constitutes a barrier to the passive movement of substances from the blood into the cerebral microenvironment, and disruption of this barrier after a stroke or trauma has potentially fatal consequences. Reactive oxygen species (ROS), which are formed during these cerebrovascular accidents, have a key role in this disruption. ROS are formed constitutively by mitochondria and also by the activation of cell receptors that transduce signals from inflammatory mediators, e.g., activated phospholipase A₂ forms arachidonic acid that interacts with cyclooxygenase and lipoxygenase to generate ROS. Endothelial NADPH oxidase, activated by cytokines, also contributes to ROS. There is a surge in ROS following reperfusion after cerebral ischemia and the interaction of the signaling pathways plays a role in this. This review critically evaluates the literature and concludes that the ischemic penumbra is a consequence of the initial edema resulting from the ROS surge after reperfusion.

Neuroprotection: extrapolating from neurologic diseases to the eye

PURPOSE

To review the current status of neuroprotection in ophthalmic disease.

DESIGN

Perspective.

METHODS

Published and unpublished data on neuroprotection in neurologic and ophthalmologic diseases were reviewed and interpreted.

RESULTS

Almost all clinical studies of neuroprotection in neurologic and ophthalmologic disease so far have failed to show efficacy, despite encouraging preclinical studies.

CONCLUSIONS

Achievement of consensus on how to design and execute translational research in neuroprotection in ophthalmic disease would optimize the use of resources and would hasten the development and approval of effective neuroprotective agents.

Future of neuroprotection for acute stroke: in the aftermath of the SAINT trials

The concept of neuroprotective therapy for acute ischemic stroke to salvage tissue at risk and improve functional outcome is based on sound scientific principles and extensive preclinical animal studies demonstrating efficacy. The failure of most neuroprotective drugs in clinical trials has been due to inadequate preclinical testing and flawed clinical development programs. The Stroke Therapy Academic Industry Roundtable (STAIR) group has outlined rational approaches to preclinical and clinical studies. The positive results from the first Stroke-Acute-Ischaemic-NXY-Treatment (SAINT-I) trial of the free-radical spin-trap drug, NXY-059, which followed many of the STAIR guidelines, reinvigorated enthusiasm in neuroprotection, but the SAINT-II trial did not replicate the positive effect on the same primary prespecified outcome measure. This has led to concerns about the future of neuroprotection as a therapeutic strategy for acute ischemic stroke. We discuss new suggestions to bridge the chasm between preclinical animal modeling and acute human stroke trials to potentially enhance the future assessment of novel neuroprotective drugs.

Tacrolimus, a potential neuroprotective agent, ameliorates ischemic brain damage and neurologic deficits after focal cerebral ischemia in nonhuman primates

Tacrolimus (FK506), an immunosuppressive drug, is known to have potent neuroprotective activity and attenuate cerebral infarction in experimental models of stroke. Here we assess the neuroprotective efficacy of tacrolimus in a nonhuman primate model of stroke, photochemically induced thrombotic occlusion of the middle cerebral artery (MCA) in cynomolgus monkeys. In the first experiment, tacrolimus (0.01, 0.032, or 0.1 mg/kg) was intravenously administered immediately after MCA occlusion, and neurologic deficits and cerebral infarction volumes were assessed 24 hours after the ischemic insult. Tacrolimus dose-dependently reduced neurologic deficits and infarction volume in the cerebral cortex, with statistically significant amelioration of neurologic deficits at 0.032 and 0.1 mg/kg and significant reduction of infarction at 0.1 mg/kg. In the second experiment, the long-term efficacy of tacrolimus on neurologic deficits and cerebral infarction was assessed. Vehicle-treated monkeys exhibited persistent and severe deficits in motor and sensory function for up to 28 days. A single intravenous bolus injection of tacrolimus (0.1 or 0.2 mg/kg) produced long-lasting amelioration of neurologic deficits and significant reduction of infarction volume. In conclusion, we have provided compelling evidence that a single dose of tacrolimus not only reduces brain infarction but also ameliorates long-term neurologic deficits in a nonhuman primate model of stroke, strengthening the view that tacrolimus might be beneficial in treating stroke patients.

Animal models of focal and global cerebral ischemia

The use of appropriate animal models is essential to predict the value and effect of therapeutic approaches in human subjects. Focal (stroke) and global (cardiac arrest) cerebral ischemia represents diseases that are common in the human population. Stroke and cardiac arrest, which are major causes of death and disability, affect millions of individuals around the world and are responsible for the leading health care costs of all diseases. Understanding the mechanisms of injury and neuroprotection in these diseases is critical if we are ever to learn new target sites to treat ischemia. There are many animal models available to investigate injury mechanisms and neuroprotective strategies. This review summarizes many (but not all) small and large animal models of focal and global cerebral ischemia and discusses their advantages and disadvantages.

Desmethyl tirilazad improves neurologic function after hypoxic ischemic brain injury in piglets

OBJECTIVE

Desmethyl tirilazad is a lipid-soluble free radical quencher. Deferoxamine reduces free radicals by chelating iron and reducing hydroxyl formation. Free radical inhibitors have shown promise in several hypoxic ischemic brain injury models, and we wished to see if this work could be extended to our newborn piglet model.

DESIGN

Randomized controlled trial.

SUBJECTS

Piglets (0 to 3 days old).

INTERVENTION

Carotid snares and arterial and venous catheters were placed under 1.5% isoflurane anesthesia. In Experiment 1, piglets were randomly assigned to receive either 3 mg/kg desmethyl tirilazad or vehicle at -15 and 90 mins. In Experiment 2, piglets were randomly assigned to receive either 20 mg/kg desmethyl tirilazad at -15 mins followed by 8 mg/kg/hr for 90 mins or 100 mg/kg deferoxamine at -15 mins or vehicle. At time 0, both carotid arteries were clamped and blood was withdrawn to reduce the blood pressure to two-thirds normal. At 15 mins, inspired oxygen was reduced to 6%. At 30 mins, the carotid snares were released, the withdrawn blood was reinfused, and the oxygen was switched to 100%. On the third day after the hypoxic ischemic injury, the animals were killed by perfusing their brains with 10% formalin. We tested the timing of lipid peroxidation and inhibition of lipid peroxidation by these agents by freezing the brains of a subset of pigs in liquid nitrogen.

MEASUREMENTS

Neurologic examination and brain pathology were scored by blinded observers. Thiobarbituric acid-reactive substance and oxidized and reduced glutathione were measured on frozen brains.

MAIN RESULTS

Desmethyl tirilazad (20 mg/kg) and 100 mg/kg deferoxamine inhibit lipid peroxidation. Desmethyl tirilazad (20 mg/kg) improves neurologic exam, but 3 mg/kg Desmethyl tirilazad or 100 mg/kg deferoxamine does not. Neither desmethyl tirilazad nor deferoxamine improves pathologic results.

CONCLUSIONS

High-dose desmethyl tirilazad improves neurologic function after hypoxic ischemic brain injury in the newborn piglet.

Adenosine receptor blockade and nitric oxide synthase inhibition in the retina: impact upon post-ischemic hyperemia and the electroretinogram

We preformed this study to determine the effect on ocular blood flow and the electroretinogram of either nitric oxide synthase (NOS) inhibition, adenosine receptor blockade or the combination of both after 1 hr of ocular ischemia. Thirty-seven cats under general anesthesia were subjected to 1 hr of complete ischemia in one eye by raising the intraocular pressure above systolic blood pressure. The other eye in each animal served as a non-ischemic control. Arterial blood gas tension, systemic arterial pressure, body temperature, hematocrit, and anesthetic level were controlled in each experiment. Cats were divided into four groups. Group 1 received normal saline injections [intravenous (i.v.) and intravitreal], Group 2 adenosine receptor blockade (0.1 ml of 0.01 M 8-sulfophenyltheophylline intravitreal) and saline i.v., Group 3 NOS inhibition (30 mg/kg l-NG-nitroarginine-methyl-ester i.v.) and saline intravitreal, and Group 4 intravitreal adenosine receptor blockade and NOS inhibition i.v. A subset of Group 3 received l-arginine to investigate the reversibility of NOS inhibition, after the blood flow measurements were completed. Five minutes after the end of ischemia, blood flows in retina and choroid were measured using injections of radioactively labeled microspheres. Electroretinographic (ERG) studies were carried out before treatment, before ischemia, during ischemia, and 1, 2, 3, and 4 hr after ischemia ended. NOS inhibition significantly reduced basal blood flow in the choroid, and in the retina when combined with adenosine receptor blockade. Adenosine receptor blockade completely attenuated post-ischemic hyperemia in the retina, but retinal hyperemia reappeared when adenosine receptor blockade and NOS inhibition were combined. Adenosine receptor blockade had no effect on ERG recovery after ischemia. NOS inhibition led to a reduction of ERG a- and b-wave amplitudes in control eyes, that could be reversed by l-arginine. Nitric oxide (NO) appears to be a significant factor in the regulation of basal blood flow in the choroid. Adenosine appears to be a major mediator of retinal hyperemia after 60 min of ischemia. Since NOS inhibition appeared to have direct effects on ERG wave amplitudes, short-term ERG studies may be of limited use in assessing the role of NO in postischemic recovery of the retina. Our observations correlate well with the emerging role of NO as a neurotransmitter in the retina.

Delayed adjuvant therapy with the 21-aminosteroid U74006F and the anion channel blocker L644-711 does not improve outcome following thrombolytic therapy in a rabbit model of thromboembolic stroke

BACKGROUND

Both the 21-aminosteroid U74006F, a potent inhibitor of lipid peroxidation, and L644-711, an anion channel blocker that inhibits both neutrophil and astrocyte function, have been previously shown to reduce brain injury in pretreatment paradigms of cerebral ischemia. It was therefore of interest to examine the effect of these agents in combination, when given on a delayed basis as adjuvants to thrombolytic therapy in a rabbit model of thromboembolic stroke.

METHODS

Animals were mechanically ventilated and arterial blood gases controlled. Core and brain temperature, intracranial pressure, and mean arterial pressure were continuously monitored. Regional cerebral blood flow and hematocrit were measured hourly. Blood samples were taken to measure neutrophil (aggregation and chemiluminescence) and platelet (aggregation) activity. Following delivery of an autologous clot via the carotid artery, all experiments were continued for an 8-hour period. U74006F (3 mg/kg I.V.) and L644,711 (12 mg/kg I.V.) or their vehicle control (n = 8, each group) were given 3.5 hours following autologous clot embolization. Both groups received tissue-type plasminogen activator (t-PA) (6.3 mg/kg I.V.), beginning 4 hours following thromboembolic stroke and continuing over a 2-hour infusion period. Infarct size was determined following staining and image analysis.

RESULTS

In the L644,711/U74006F group, neutrophil chemiluminescence was reduced following drug therapy; however, there were no significant differences between groups regarding infarct size (50.3 +/- 8.7 vs. 49.9 +/- 10.6, treatment vs. t-PA control, mean +/- SEM), or in regional cerebral blood flow or intracranial pressure over time.

CONCLUSIONS

It is concluded that prolonged (3.5 hours) delay of the initiation of therapy with the anion channel blocker L644,711 and the 21-aminosteroid U74006F fails to further reduce brain injury when given in combination with tissue plasminogen activator in a rabbit model of thromboembolic stroke.

Lazaroids: Mechanisms of Action and Implications for Disorders of the CNS

Oxygen radical-induced lipid peroxidation to cerebrovascular or brain parenchymal cell membranes has been implicated as a pathophysiological mechanism in both acute and chronic neurodegenerative disorders, including brain and spinal cord trauma, ischemic and hemorrhagic stroke, Alzheimer's and Parkinson's diseases, and amyotrophic lateral sclerosis. As a result, pharmacological strategies have been aimed at antagonizing lipid peroxidative damage in a safe and effective manner. Perhaps the first successful antioxidant neuroprotective approach is high dose treatment with the glucocorticoid steroid methylprednisolone, which has been reported to be effective in improving neurological recovery after blunt spinal cord injury in animals and humans. After a determination that these effects were based upon inhibition of posttraumatic lipid peroxidative reactions rather than steroid receptor interactions, a new class of 21-aminosteroids (“lazaroids”) was discovered. The lazaroids are more effective inhibitors of lipid peroxidation and, at the same time, devoid of glucocorticoid side effect potential. One of them, tirilazad (U-74006F), was found protective in a variety of preclinical neuroprotection models and is currently the subject of Phase III clinical trials. Thus far, the compound has been demonstrated to significantly improve 3-month survival and neurological recovery after subarachnoid hemorrhage in humans. Although tirilazad does penetrate the injured CNS, much of its protective activity is mediated by an action on vascular endothelium. Recently, the 21-aminosteroids have been followed up with a newer series of non-steroidal compounds, the pyrrolopyrimidines, which possess even greater antioxidant efficacy and brain penetration that may be useful for the treatment of chronic neurodegenerative disorders.

Tirilazad prevention of reperfusion edema after focal ischemia in cynomolgus monkeys

BACKGROUND

The purpose of the present investigation was to determine if post-ischemic treatment with the 21-aminosteroid lipid peroxidation inhibitor tirilazad mesylate (U-74006F) could affect reperfusion brain edema during the first 3h following a 3h period of middle cerebral artery occlusion-induced focal ischemia in cynomolgus monkeys.

METHODS

Adult female cynomolgus monkeys (N = 14) were subjected under halothane anesthesia to a 3h period of middle cerebral artery occlusion, followed by 3h of reperfusion. U-74006F, 3.0 mg/kg i.v. or citrate vehicle, was administered 10 min before beginning reperfusion. Multiple spin-echo (8 echoes: TE = 26.3 msec; TR = 3.0 secs; 2.35 Tesla) magnetic resonance imaging was performed every 30 min, beginning at 1h after reperfusion. Transverse relaxation rates (T2) for the caudate, putamen, cortex, insular cortex, parietal cortex and central white matter were calculated as an index of focal brain edema. After the final images, corresponding regions were removed for determination of water content by the wet weight/dry weight method.

RESULTS

The T2 measurements strongly suggested the presence of post-reperfusion edema in all gray matter, but not white matter, regions at 1h after reperfusion in vehicle-treated animals. Significant attenuation of edema development was seen in the putamen and insular cortex in U-74006F-treated animals. An effect was also observed in the parietal cortex, but none in the caudate. The measurement of water content at 3h after reperfusion yielded similar results.

CONCLUSIONS

These results showing the ability of U-74006F to attenuate post-reperfusion brain edema support the concept that lipid peroxidation is a significant mediator of reperfusion brain edema after focal ischemia. The therapeutic window for U-74006F's anti-edema effect appears to be at least 3h after the onset of focal ischemia since delaying treatment until just before reperfusion largely prevented subsequent edema in cortical regions and the putamen. The effects of U-74006F on edema may play a mechanistic role in the compound's reported neuroprotective efficacy in a variety of focal ischemia models.

Inhibition of lipid peroxidation in central nervous system trauma and ischemia

A novel group of compounds, the 21-aminosteroids ("lazaroids"), have been designed that are potent inhibitors of oxygen free radical-induced, iron-catalyzed lipid peroxidation (LP) in microvascular and nervous tissue. One of these, tirilazad mesylate (U-74006F), has been selected for clinical evaluation as a cerebroprotective agent. In vitro studies suggest that tirilazad exerts its antioxidant activity by multiple mechanisms including: increasing membrane stability, scavenging of lipid peroxyl radicals, reducing LP-induced arachidonic acid release, decreased formation or scavenging of hydroxyl radicals, and maintenance of the levels of endogenous vitamin E. The major site of action appears to be the blood-brain barrier based upon its known localization in cerebrovascular endothelium and numerous studies showing an attenuation of subarachnoid hemorrhage (SAH), injury, and ischemia-induced blood-brain barrier permeability. Tirilazad has demonstrated neuroprotective efficacy in multiple preclinical models of spinal cord and head injury, SAH, and focal cerebral ischemia, as measured by a decrease in cerebral vasospasm, blood-brain barrier compromise, post-traumatic ischemia, edema, ischemic neuronal necrosis and infarction, and improved neurological recovery. This efficacy is correlated with a reduction in markers of oxygen radical-induced LP. Phase III clinical trials are currently ongoing in spinal cord and head injury, SAH, and ischemic stroke. Initial results from a European/Australian/New Zealand trial in SAH have shown a significant decrease in mortality and an increase in the incidence of good recovery.

Post-ischemic hyperemia in the cat retina: the effects of adenosine receptor blockade

Significant hyperemia results after 1 h of retinal ischemia in cats. Adenosine receptor blockade significantly attenuates the increase in retinal blood flow that occurs in response to systemic hypoxia. Synthesizing these findings, I hypothesized that adenosine receptor antagonism would attenuate the increase in blood flow that follows retinal ischemia. In these experiments, blood flows were measured with radioactively labeled microspheres in the retina and choroid of adult cats anesthetized with chloralose and acepromazine. Ischemia was induced for 1 h in both eyes by elevation of intraocular pressure above systolic arterial pressure. Blood flows were measured before ischemia and 5 min after the return of normal intraocular pressure. In each animal, after baseline blood flows were determined and approximately 10-15 min before ischemia was induced, one eye received 0.1 ml of intravitreal 0.01M 8-sulfophenyltheophylline, a polar adenosine receptor antagonist, while the opposite eye, the control, received an equal volume of intravitreal saline. Arterial blood gas tensions, systemic arterial pressure, hematocrit, and anesthetic level were kept constant during the experimental protocol. Compared with control eyes, hyperemia was significantly attenuated in the retinal circulation after ischemia in eyes injected with 8-sulfophenyltheophylline. Increase in post-ischemic choroidal blood flow was not affected. Although adenosine is involved in the vasodilatation that occurs when blood flow is restored after retinal ischemia, adenosine receptor blockade did not completely abolish hyperemia, implying that blockade was incomplete or other vasoactive substances also affect post ischemic hyperemia in the retina.

[Pharmacologic brain protection: specific agents]

Dysfunctional sodium influx is the first step in the ischaemic cascade. It has been recently demonstrated that reducing ionic flux through voltagegated Na channels shortens the NMDA receptor activity of cultured hippocampal slices in which oxidative phosphorylation and glycolysis have been blocked. The implication of this finding is that blocking initial events in the ischaemic cascade, events which do not directly cause neuronal damage, will reduce the damage done by downstream events. It also seems intuitively reasonable to suppose that truncating initial steps of the ischaemic cascade, as distinct from blocking glutamate receptors and scavening free radicals, will reduce the probability of interfering with endogenous mechanisms of repair. Clinically useful, substantive, prophylactic, pharmacological cerebral protection will come from drugs that work upstream. And for pharmacological protection that can only be initiated subsequent to an ischaemic event, the more we learn about endogenous repair, or genetic pharmacology, the closer we will come to maximizing the benefits and minimizing the costs of downstream intervention.