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Ischemic stroke is a cerebrovascular disease normally caused by interrupted blood supply to the brain. Ischemia would initiate the cascade reaction consisted of multiple biochemical events in the damaged areas of the brain, where the ischemic cascade eventually leads to cell death and brain infarction. Extensive researches focusing on different stages of the cascade reaction have been conducted with the aim of curing ischemic stroke. However, traditional treatment methods based on antithrombotic therapy and neuroprotective therapy are greatly limited for their poor safety and treatment efficacy. Nanomedicine provides new possibilities for treating stroke as they could improve the pharmacokinetic behavior of drugs in vivo, achieve effective drug accumulation at the target site, enhance the therapeutic effect and meanwhile reduce the side effect. In this review, we comprehensively describe the pathophysiology of stroke, traditional treatment strategies and emerging nanomedicines, summarize the barriers and methods for transporting nanomedicine to the lesions, and illustrate the latest progress of nanomedicine in treating ischemic stroke, with a view to providing a new feasible path for the treatment of cerebral ischemia., Graphical abstract This review summarizes various nanomedicines, including liposomes, micelles, dendrimer, nanoparticles, and exosomes, which have been applied for the treatment of ischemic stroke. It especially focuses on their abilities to normalize various abnormalities at different phases of ischemic cascade, such as dissolving the clot and salvaging the penumbra.Image 1

Stroke is the second, and in some countries the third cause of mortality in the population and one of the causes of disability in the adult population. According to statistics, in 2018, 15 million cases of stroke and 6 million deaths were diagnosed,The only currently approved treatments for acute stroke are intravenous tissue plasminogen activator (rtPA) and intra-arterial thrombectomy, which are used in less than 10% and 1% of patients, respectively.The literature review is devoted to the pathophysiology and molecular mechanisms of damage in cerebral ischemia. The modern concept of two strategies of cell therapy is discussed: neuroprotection and remodeling; the role of stem cells in reducing local and systemic inflammation, neurogenesis and angiogenesis, increasing neuronal plasticity, and protecting the blood-brain barrier, the role of paracrine factors and extracellular vesicles is shown.Methods of stem cell delivery are described: direct intracerebral transplantation, intraventricular and intrathecal, intravenous and intraarterial; the number of cells, their type and optimal delivery time depending on the acute, subacute and chronic periods of stroke. We also described recently designed the radially branched deployment (RBD) device and Cleveland multiport catheter for convection-enhanced delivery in which a cell-delivery catheter can be deployed at various angles and depths from a single longitudinal cannula. Finally, data on the completed 15 clinical trials from 2015 to the present, in which 513 patients took part, are presented. A detailed analysis of the efficacy and safety of cell therapy has been carried out.

Обзор посвящен рассмотрению современных подходов к фармакологической модуляции структурно-функционального состояния митохондриального аппарата нейронов как перспективной стратегии терапии ишемического инсульта головного мозга, составляющего по современным оценкам до 85% всех случаев острого нарушения мозгового кровообращения. В обзоре проведен анализ классических представлений о нейропротекции как терапии, направленной на блокирование ключевых патогенетических звеньев «ишемического каскада», в контексте современного понимания приоритетной роли коррекции митохондриальной дисфункции в ограничении механизмов повреждения при церебральной ишемии. Обсуждаются возможности применения препаратов плейотропного нейропротекторного действия, реализующих митохондриально-направленные защитные эффекты через модуляцию активности транскрипционного коактиватора PGC-1α (peroxisome proliferator-activated receptor-1γ coactivator-1α), контролирующего процессы биогенеза митохондрий, ангиогенеза, ферментативное звено антиоксидантной системы. The review addresses modern approaches to pharmacological modulation of structure and function of the neuronal mitochondrial apparatus. This is a promising strategy for therapy of ischemic stroke, which accounts for up to 85% of all cases of acute cerebrovascular disease. The review analyzes classical concepts of neuroprotection as a therapy aimed at blocking key pathogenetic components of the “ischemic cascade”. These concepts are based on current ideas about the importance of correcting mitochondrial dysfunction for alleviation of damage in cerebral ischemia. The authors discussed possibilities of using pleiotropic neuroprotectors that implement mitochondrial-targeted protective effects by modulating the activity of transcriptional coactivator, peroxisome proliferator-activated receptor-1γ coactivator-1α (PGC-1α), which controls mitochondrial biogenesis, angiogenesis, and the enzymatic antioxidant system.

According to the World Health Organization, about 5 million people die every year from cerebrovascular disease. At the same time, the proportion of cerebral infarction, or ischemic stroke (IS), among forms of acute cerebrovascular accident reaches 80-85%. Despite the active study of biochemical and morphological changes leading to acute cerebrovascular ischemia, the problem of early diagnosis, prevention, as well as predicting the outcome of this disease is still relevant. There is no doubt that the interruption of the ischemic cascade at earlier stages can be accompanied by a greater effect of treatment. A timely and effective pharmacological intervention requires a clear understanding of the pathochemical and biological processes underlying acute ischemia at the molecular level. High mortality and disability accompanying acute IS, dictate the need to create new diagnostic and prognosis algorithms both in the acute period of IS, and in the recovery period. According to some authors, elucidation of the pathways that underlie the pathogenetic mechanisms acting in the penumbra are of great clinical interest for the development of new diagnostic and therapeutic strategies. Studying the mechanisms of apoptosis and autophagy of neurons in the dynamics of the acute period of IS, modulation of the autophagy process in the penumbra zone can contribute to the development of new methods for the diagnosis and treatment of acute IS. The review presents the results of the latest experimental studies on the role of apoptosis and autophagy in the development of acute cerebral ischemia and attempts to modulate these processes in order to influence the ischemic cascade. The review was based on sources from such international and national data bases as Scopus, Web of Science, Springer, RINC.

Stroke is a neurological emergency, where the mechanism of the blood supply to the brain is impaired, resulting in brain cell ischemia and death. Neuroinflammation is a key component in the ischemic cascade that results in cell damage and death after cerebral ischemia. The triggering receptor expressed on myeloid cells-1 (TREM-1) modulates neuroinflammation after acute ischemic stroke. In the present study, 60 patients with acute ischemic stroke, who had been subjected to neurological examinations and National Institutes of Health Stroke Scale (NIHSS) and brain magnetic resonance imaging studies, were enrolled in the emergency room of Kaohsiung Chang Gung Memorial Hospital. Twenty-four healthy volunteers were recruited as controls. The serum levels of soluble TREM-1 (sTREM-1), human S100 calcium-binding protein B (S100B), and proinflammatory cytokines and chemokines, including tumor necrosis &alpha, (TNF-&alpha, ), interleukin 1&beta, interleukin 6 (IL-6), interleukin 8, and interferon-&gamma, were measured immediately after acute ischemic stroke. The serum levels of sTREM-1, TNF&alpha, IL-6, and S100B were correlated with the stroke volume and NIHSS, after acute ischemic stroke. Additionally, the serum levels of sTREM-1 were significantly positively correlated with S100B. The functional outcomes were evaluated 6 months after ischemic stroke by the Barthel index, which was correlated with the age and levels of sTREM-1 and S100B. We suggest that acute ischemic stroke induces neuroinflammation by the activation of the TREM-1 signaling pathway and the downstream inflammatory machinery that modulates the inflammatory response and ischemic neuronal cell death. From a translational perspective, our results may allow for the development of a new therapeutic strategy for acute ischemic stroke by targeting the TREM-1 signaling pathway.

The ischemic cascade is initiated in the hypoperfused region of the brain that leads to neuronal cell death. Identification of multi-target inhibitor against prominent molecular mediators of ischemic cascade might be a suitable strategy to combat cerebral ischemic stroke. The present study is designed to evaluate the neuroprotective efficacy of chlorogenic acid (CGA) in the global cerebral ischemic rat model. The effective dose of CGA was evaluated on the basis of reduction in cerebral infarction area percentage, Evans blue extravasation, and restoration of brain water content. The expression of tumor necrosis factor-α (TNF-α), inducible nitric oxide synthase (iNOS), and caspase-3 was evaluated by immunohistochemistry and morphological and cellular alterations in the cortex were observed by brain histology. The level of glutamate, calcium, and nitrate in different regions of the brain, as well as cerebrospinal fluid (CSF), was evaluated. The level of calcium and nitrate was compared with ifenprodil-an antagonist of N-methyl-D-aspartate receptor (NMDAR) and 7-nitroindazole-an inhibitor of neuronal nitric oxide synthase (nNOS) respectively. Further, molecular docking was performed to compare the inhibition potential of CGA against NMDAR and nNOS with their inhibitors. Dose optimization results revealed that intranasal administration of CGA (10 mg/kg b.w.) significantly reduced the cerebral infarction area, Evans blue extravasation and restored the brain water content compared with ischemia group. It also significantly reduced the calcium, nitrate, and glutamate levels compared with ischemia group in the cortex, hippocampus cerebellum, and CSF. Immunohistochemical analysis revealed that CGA significantly reduced the expression of TNF-α, iNOS, and caspase-3 as compared with the ischemia group. In molecular docking study, CGA displayed similar binding interaction as that of Ifenprodil and 7-nitroindazole with NMDAR and nNOS respectively. The current findings suggest that the treatment with CGA confers neuroprotection in global ischemic insult by inhibiting and downregulating the different molecular markers of cerebral ischemia.

The advent of mechanical thrombectomy and increasing alteplase use have transformed the care of patients with acute ischemic stroke. Patients with major arterial occlusions with poor outcomes now have a chance of returning to independent living in more than half of the cases. However, many patients with these severe strokes suffer major disability despite these therapies. The search is ongoing for agents that can be combined with thrombectomy to achieve better recovery through halting infarct growth and mitigating injury after ischemic stroke. Several studies in animals and humans have demonstrated that therapeutic hypothermia (TH) offers potential to interrupt the ischemic cascade, reduce infarct volume, and improve functional independence. We performed a literature search to look up recent advances in the use of TH surrounding the science, efficacy, and feasibility of inducing TH in modern stroke treatments. While protocols remain controversial, there is a real opportunity to combine TH with the existing therapies to improve outcome in adults with acute ischemic stroke.

Purpose To demonstrate the ability of widefield en face swept source optical coherence tomography (OCT) imaging to monitor peri-venular fern-like patterns of paracentral acute middle maculopathy (PAMM) associated with retinal arterial occlusions. Observations The peri-venular fern-like pattern of PAMM was diagnosed on the 12 × 12 mm en face structural OCT images from three patients. Fluorescein angiography images were unremarkable. Over time, all three patients demonstrated significant improvement in visual acuity with resolution of their peri-venular PAMM. Conclusions The peri-venular fern-like pattern of PAMM is usually associated with retinal vein occlusions, but we identified three cases with this pattern in eyes with presumed incomplete retinal arterial occlusions. Our cases support the ischemic cascade theory that begins within the deep capillary plexus and ascends in the retina depending on the severity of the ischemic event. Using the 12 × 12 mm en face structural OCT images, we are able to demonstrate a wider area of ischemia in PAMM compared with the traditional 6 × 6 mm scans.

Ischemic Stroke precedes depression . Post Stroke Depression (PSD) is a major driver for poor recovery, negative quality of life, poor rehabilitation outcomes and poor functional ability. This systematic reviews confirmed the post stroke depression as the norm as complex ischemic cascade involve the bioenergetic failure, deranged iron homeostasis ( calcium influx, Na influx, potassium efflux etc) excitotoxicity, acidotoxicity,disruption of the blood brain barrier, cytokine mediated cytotoxicity, reactive oxygen mediated toxicity , activation of cyclooxygenase pathway and generation of toxic products, infiltration of immune mediated cells resulting the cell death and deranged neuronal networks in mood related brain regions. This review focus on the pathobiology of stroke in the context and make the argument that PSD is the norm after a stroke rather than the exception.

Purpose To report a case of paracentral acute middle maculopathy (PAMM) and evidence of the ischemic cascade documented with spectral domain optical coherence tomography (SD-OCT) following radiation treatment of a choroidal melanoma. Observations A healthy young patient was evaluated for an asymptomatic choroidal nevus in the left eye. Fundus examination was remarkable for a choroidal melanocytic lesion that measured 1.8 mm in thickness by initial B-scan ultrasound. Clinical examination 6 months later showed growth of the tumor at several margins with new subretinal fluid, and a B-scan measured thickness of 1.9 mm. The lesion was diagnosed as a small choroidal melanoma and treated with gamma knife radiation with a dose of 3000 cGy. Sixteen months later, examination showed signs of radiation retinopathy including cotton wool spots and PAMM via SD-OCT and OCT angiography and evidence of the ischemic cascade i.e. alternating zones of middle and combined middle and inner retinal layer infarction. Conclusions and Importance: Radiation retinopathy can include signs of microvascular damage and ischemia including lesions such as cotton wool spots and PAMM. A case is presented in this report of radiation retinopathy with OCT evidence of PAMM and the ischemic cascade.

Cerebral ischemia constitutes the most frequent type of cerebrovascular disease. The reduction of blood supply to the brain initiates the ischemic cascade starting from ionic imbalance to subsequent glutamate excitotoxicity, neuroinflammation and oxidative stress, eventually causing neuronal death. Previously, the authors have demonstrated the in vitro cytoprotective and antioxidant effects of a new arylidene malonate derivative, KM-34, against oxidizing agents like hydrogen peroxide, glutamate or Fe3+/ascorbate. Here, we examined for the first time the neuroprotective effect of KM-34 on ischemia/reperfusion models. In vitro, treatment with 10 and 50 μM KM-34 reduced the cellular death (propidium iodide incorporation) induced by oxygen glucose deprivation (OGD) in rat organotypic hippocampal slices cultures. In vivo, stroke was induced in male Wistar rats through middle cerebral artery occlusion (MCAO), followed by 23 h of reperfusion. KM-34 was orally administered 105 min after MCAO onset. We noticed that 1 mg/kg KM-34 reduced infarct volume and neurological score, and increased the latency to fall in the Hanging Wire test compared to vehicle-treated ischemic animals. While ischemic and sham-operated groups showed similar horizontal locomotor activity, vertical counts decreased after MCAO, suggesting that vertical movements are more sensitive to the ischemic injury. Treatment with KM-34 also alleviated the mitochondrial impairment (ROS generation, swelling and membrane potential dissipation) induced by transient MCAO but not significant alterations were found in oxidative stress parameters. Overall, the study provides preclinical evidences confirming the neuroprotective effects of a novel synthetic molecule and paved the way for future investigations regarding its therapeutic potential against brain ischemia/reperfusion injury.

This review is aimed at understanding the clinical connect betweenischemia and tissue changes by firstly, describing the historical and clinicopathophysiologicalperspective of deformation imaging and secondly clinical advances of tissue imaging; nextthe body of evidence currently available for this methodology; and finally, the feasibility andbarriers to clinical translation. There will also be a brief review of the feasibility and currentuse of contrast for perfusion with flash imaging Myocardial contrast echocardiography (MCE) for the detection of ischemia. Myocardial ischemia detection has come a long way since the clinicalsymptom was scientifically described several centuries ago and matched withpathophysiological correlation. The majority of cases are atherosclerotic macro-vesselobstruction or thrombosis and lesser degree various other forms of obstruction includingdynamic changes in both small and large vascular beds. On a statistical level most lifethreatening cases are atherosclerotic and correlated physiologically with an ischemiccascade. With the identification of non-linearity of ischemic cascade and hence concepts ofischemic constellation, it is increasingly clear that circumstances can determine which aspectof the cascade is noted and altering the probability of significant ischemi a. Myocardial deformation and perfusion imaging adds a novel perspective of myocardial performance under stress.

Retinal ischemia is involved in the pathogenesis of many major vision threatening diseases. Vinpocetine is a natural drug, which has a range of neuroprotective actions against retinal ischemia including modulating cation flow, improving metabolic activity and preventing apoptosis. The exact mechanism behind these actions remains unknown but may involve glutamate receptors, major components of the ischemic cascade. This study examined the effects of vinpocetine in association with specific ionotropic glutamate receptor agonists: N-methyl-D-aspartate (NMDA) and kainate. Vinpocetine's actions to improve cation channel permeability and cell marker immunoreactivity following ischemia appeared to be limited to NMDA activation with no changes observed following kainate stimulation. Vinpocetine's actions were lost in the presence of an NMDA receptor inhibitor further suggesting they may be secondary to NMDA receptor activation. NMDA receptor function was also necessary for vinpocetine's actions on glucose availability during ischemia but not lactate dehydrogenase (LDH) activity in the ischemic retina suggesting not all of vinpocetine's actions are linked to NMDA receptor function. These results may explain vinpocetine's effectiveness as a neuroprotective agent as the NMDA receptor is implicated in the pathogenesis of ischemia in a range of tissues of the central nervous system.

In stroke (cerebral ischemia), despite continuous efforts both at the experimental and clinical level, the only approved pharmacological treatment has been restricted to tissue plasminogen activator (tPA). Stroke is the leading cause of functional disability and mortality throughout worldwide. Its pathophysiology starts with energy pump failure, followed by complex signaling cascade that ultimately ends in neuronal cell death. Ischemic cascade involves excessive glutamate release followed by raised intracellular sodium and calcium influx along with free radicals’ generation, activation of inflammatory cytokines, NO synthases, lipases, endonucleases and other apoptotic pathways leading to cell edema and death. At the pre-clinical stage, several agents have been tried and proven as an effective neuroprotectant in animal models of ischemia. However, these agents failed to show convincing results in terms of efficacy and safety when the trials were conducted in humans following stroke. This article highlights the various agents which have been tried in the past but failed to translate into stroke therapy along with key points that are responsible for the lagging of experimental success to translational failure in stroke treatment.

MPI evaluates myocardial perfusion defect (PD) and changes in blood flow (MBF) that occur early in the ischemic cascade, eventually leading to angina. Few data exist on link between MPI findings and health status. Health status was collected using the Seattle Angina Questionnaire (SAQ-7, 0-100

Myocardial perfusion abnormalities are the first sign of the ischemic cascade in the development of coronary artery disease (CAD). Thus, the early detection of myocardial perfusion abnormalities is significant for the prevention of CAD. Recently, a novel noninvasive method named Cardiodynamicsgram (CDG) has been proposed for early detection of CAD. This study aims to evaluate the predictive value of CDG in myocardial perfusion abnormalities for suspected ischemic heart disease. In the study, 86 suspected patients were enrolled. Standard 12-lead ECG and CDG were performed simultaneously before single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). Diagnostic accuracy of CDG for myocardial perfusion abnormalities detection is assessed using SPECT MPI as the reference standard. Of these 86 suspected patients, 37 patients were positive in CDG, 49 patients were negative in CDG. Diagnostic accuracy of CDG at presentation for myocardial perfusion abnormalities was 84.9%, sensitivity 84.0%, and specificity 89.4%. Furthermore, of the 10 patients whose SPECT MPI results are reverse redistribution, 9 patients were positive in CDG. Underlying causes of false positive CDG findings included the factors that can change the stability of cardiac electrical conduction and measurement noise. Myocardial remodeling in patients with old myocardial infarction might be the major cause of false negative findings. Results show a good consistency between the CDG and SPECT MPI in evaluating myocardial perfusion abnormalities. It suggests that CDG might be used as a cost-effective tool for assessing the myocardial perfusion abnormalities in the clinic.

Neuroprotective treatments in ischemic stroke are focused to reduce the pernicious effect of excitotoxicity, oxidative stress and inflammation. However, those cellular and molecular mechanisms may also have beneficial effects, especially during the late stages of the ischemic stroke. The objective of this study was to investigate the relationship between the clinical improvement of ischemic stroke patients and the time-dependent excitotoxicity and inflammation. We included 4295 ischemic stroke patients in a retrospective study. The main outcomes were intra and extra-hospital improvement. High glutamate and IL-6 levels at 24 hours were associated with a worse intra-hospital improvement (OR:0.993, 95%CI: 0.990–0.996 and OR:0.990, 95%CI: 0.985–0.995). High glutamate and IL-6 levels at 24 hours were associated with better extra-hospital improvement (OR:1.13 95%CI, 1.07–1.12 and OR:1.14, 95%CI, 1.09–1.18). Effective reperfusion after recanalization showed the best clinical outcome. However, the long term recovery is less marked in patients with an effective reperfusion. The variations of glutamate and IL6 levels in the first 24 hours clearly showed a relationship between the molecular components of the ischemic cascade and the clinical outcome of patients. Our findings suggest that the rapid reperfusion after recanalization treatment blocks the molecular response to ischemia that is associated with restorative processes.

Purpose To analyze the spectrum of ischemia associated with paracentral acute middle maculopathy (PAMM) in eyes with acute retinal vascular occlusion and to describe an ischemic cascade. Design A retrospective observational case series. Methods Patients presenting with PAMM secondary to acute retinal vascular occlusion were identified. Analysis of multimodal imaging was performed at baseline and at follow-up visits to elucidate the patterns and progression of ischemia within the retinal layers. Results Multimodal retinal imaging from 16 eyes of 16 patients with acute retinal vascular occlusion associated with PAMM was studied. Analysis of en face optical coherence tomography (OCT) segmentation of the inner nuclear layer (INL) identified distinct patterns of PAMM correlating with the severity of ischemia and not the type of occlusion. A perivenular fern-like PAMM pattern was associated with better visual outcomes (average final visual acuity was 20/25). This pattern was noted to sequentially progress in 2 cases to a diffuse globular PAMM pattern in the INL, or to a pattern of ischemia involving both the middle and inner retinal layers with commensurate vision loss. Globular patterns of PAMM or ischemia involving both the middle and inner retina correlated with poorer visual outcomes (average final visual acuity was counting fingers at 5.5 ft). These various patterns of ischemia developed in eyes with retinal vascular occlusions in which blood flow through the retinal capillary plexuses was present but was significantly reduced and delayed. Conclusions This study describes OCT findings suggestive of an ischemic cascade in eyes with retinal vascular occlusion. The middle retina at the level of the deep capillary plexus, especially at the venular pole, may be more vulnerable to ischemic injury.

Therapeutic hypothermia (TH) is a potent neuroprotective therapy in experimental cerebral ischemia, with multiple effects at several stages of the ischemic cascade. In animals, TH is so powerful that all preclinical stroke studies require strict temperature control. In humans, multiple clinical studies documented powerful protection with TH after accidental neonatal hypoxic-ischemic injury and global cerebral ischemia with return of spontaneous circulation after cardiac arrest. National and international guidelines recommend TH for selected survivors of global ischemia, with profound benefits seen. Recently, a study comparing target temperature 33-36°C failed to demonstrate significant effects in cardiac arrest patients. Additionally, clinical trials of TH for head trauma and stroke have so far failed to confirm benefit in humans despite a vast preclinical literature. Therefore, it is now critical to understand the fundamental explanation for the success of TH in some, but famously not all, clinical trials. TH in animals appears to work when used soon after ischemia onset; for a short duration; and at a deep target temperature.

Dipyridamole stress cardiac magnetic resonance (CMR) evaluates the key phases (perfusion and wall motion) of the ischemic cascade. We sought to determine the prognostic value of dipyridamole stress-CMR in consecutive patients symptomatic for chest pain. Seven hundred and ninety-three consecutive patients symptomatic for chest pain underwent dipyridamole stress-CMR and were followed up for 810 ± 665 days. Patients were classified in group 1 (no- reversible ischemia), group 2 (stress perfusion defect alone), and group 3 [stress perfusion defect plus abnormal wall motion (AWM)]. End points were "all cardiac events" (myocardial infarction, cardiac death and revascularization) and "hard cardiac events" (all cardiac events excluding revascularization). One hundred and ninety-five (24 %) all cardiac events and 53 (7 %) hard cardiac events were observed. All and hard cardiac event rates in groups 1, 2, and 3 were 11 %, 49 %, 69 % and 4 %, 8 %, 21 %, respectively, with a higher rate in group 2 vs. group 1 (p

On a subcellular level, atherogenesis is characterized by the translocation of proatherogenic lipoproteins into the arterial wall. An inflammatory response involving complex repair mechanisms subsequently causes maladaptive vascular changes resulting in coronary stenosis or occlusion. The chronology of the underlying processes occurring from atherosclerosis to myocardial ischemia affect the selection and interpretation of diagnostic testing. An understanding of the ischemic cascade, atherosclerosis, coronary remodeling, plaque morphology, and their relationship to clinical syndromes is essential in determining which diagnostic modalities are useful in clinical practice.

Ischemic stroke is a major cause of death and disability worldwide. Thrombolysis by tissue plasminogen activator is the only pharmacological treatment approved for clinical practice, but has a narrow therapeutic window and poor efficacy when the cell death cascade is activated. Numerous drugs that are thought to protect neurons against injury have previously failed in human trials despite showing efficacy in experimental models of stroke. Herein, we reviewed the main pre-clinical results of the neuroprotective effects of JM-20, a new hybrid molecule, against brain ischemia. JM-20 appears to protect the brain from ischemic damage by interfering with several elements of the ischemic cascade: antiexcitotoxic, anticalcic, antioxidant, antiapoptotic, and anti-inflammatory. Its ability to protect not only neurons but also glial cells together with its ability to target and preserve mitochondrial function makes JM-20 a promising molecule that may be able to shield the whole neurovascular unit. The multimodal and multi-cell action of JM-20 may explain the high degree of protection observed in a rat model of brain ischemia, as assayed through histological (hematoxylin-eosin, and luxol fast blue staining), neurochemical (glutamate and aspartate levels in cerebrospinal fluid), mitochondrial functionality and behavioural (neurological scale) analysis at doses of 4 and 8mg/kg. Furthermore, the wide therapeutic window of JM-20 of 8h also suggests that this molecule could be of potential interest in situations where brain perfusion is compromised.

Stroke is a devastating disorder that significantly contributes to death, disability and healthcare costs. In ischemic stroke, the only current acute therapy is recanalization, but the narrow therapeutic window less than 6 h limits its application. The current challenge is to prevent late cell death, with concomitant therapy targeting the ischemic cascade to widen the therapeutic window. Among potential neuroprotective drugs, cyclin-dependent kinase inhibitors such as (S)-roscovitine are of particular relevance. We previously showed that (S)-roscovitine crossed the blood–brain barrier and was neuroprotective in a dose-dependent manner in two models of middle cerebral artery occlusion (MCAo). According to the Stroke Therapy Academic Industry Roundtable guidelines, the pharmacokinetics of (S)-roscovitine and the optimal mode of delivery and therapeutic dose in rats were investigated. Combination of intravenous (IV) and continuous sub-cutaneous (SC) infusion led to early and sustained delivery of (S)-roscovitine. Furthermore, in a randomized blind study on a transient MCAo rat model, we showed that this mode of delivery reduced both infarct and edema volume and was beneficial to neurological outcome. Within the framework of preclinical studies for stroke therapy development, we here provide data to improve translation of pre-clinical studies into successful clinical human trials.

Abrupt deprivation of substrates to neuronal tissue triggers a number of pathological events (the "ischemic cascade") that lead to cell death. As this is a process of delayed neuronal cell death and not an instantaneous event, several pharmacological and non-pharmacological strategies have been developed to attenuate or block this cascade. The most promising neuroprotectant so far is therapeutic hypothermia and its beneficial effects have inspired researchers to further improve its protective benefit by combining it with other neuroprotective agents. This review provides an overview of all neuroprotective strategies that have been combined with therapeutic hypothermia in rodent models of focal cerebral ischemia. A distinction is made between drugs interrupting only one event of the ischemic cascade from those mitigating different pathways and having multimodal effects. Also the combination of therapeutic hypothermia with hemicraniectomy, gene therapy and protein therapy is briefly discussed. Furthermore, those combinations that have been studied in a clinical setting are also reviewed.

INTRODUCTION: Stroke is the world’s second leading cause of death. Although recombinant tissue plasminogen activator is an effective treatment for cerebral ischemia, its limitations and ischemic stroke’s complex pathophysiology dictate an increased need for the development of new therapeutic interventions. Small molecule inhibitors (SMIs) have the potential to be used as novel therapeutic modalities for stroke, since many preclinical and clinical trials have established their neuroprotective capabilities. AREAS COVERED: This paper provides a summary of the pathophysiology of stroke as well as clinical and preclinical evaluations of SMIs as therapeutic interventions for cerebral ischemia. Cerebral ischemia is broken down into four mechanisms in this article: thrombosis, ischemic insult, mitochondrial injury and immune response. Insight is provided into preclinical and current clinical assessments of SMIs targeting each mechanism as well as a summary of reported results. EXPERT OPINION: Many studies demonstrated that pre- or post-treatment with certain SMIs significantly ameliorated adverse effects from stroke. Although some of these promising SMIs moved on to clinical trials, they generally failed, possibly due to the poor translation of preclinical to clinical experiments. Yet, there are many steps being taken to improve the quality of experimental research and translation to clinical trials.

Cerebral neuroprotection for acute ischemic stroke (AIS) is defined as a therapy aimed at enhancing the brain’s resilience to ischemia to improve the clinical outcome of affected individuals. Although traditionally aimed at the salvage of neurons, this term may be equally applicable to all the cellular constituents of the brain, including cells of cerebral blood vessels, neurons, and glia. Pharmacological neuroprotection (hereafter referred to as neuroprotection) would be achieved by drugs targeting one or more critical components of the ischemic cascade that lead to ischemic damage. The feasibility of neuroprotection has a strong basis in animal experiments, but research for several decades has failed to translate neuroprotective treatments from animals to humans.1–3 The disappointing results of all controlled clinical neuroprotection trials for AIS have cast doubts as to whether neuroprotection in humans is biologically possible and, given the complexities of human stroke syndromes, whether it is a clinically practicable therapy for patients experiencing AIS in the community. The questions of feasibility and practicability cannot be resolved simultaneously. Feasibility is a question of biology: Whether it is possible to achieve tissue sparing after AIS in the high-order brains of humans? The gloomiest hypothesis is that tissue sparing and preservation of neurological function may be possible in low-order species, such as rats, but not in humans. Under this hypothesis, there might be as-yet-unresolved but fundamental anatomic, genetic, or biological differences between low-order species and humans that preclude neuroprotection in the high-order brain. However, recent studies with postsynaptic density-95 (PSD-95) protein inhibitors, a promising class of neuroprotectant that uncouple PSD-95 from neurotoxic signaling pathways in central neurons,4–7 repudiate this concern. They show that neuroprotection is unequivocally possible not only in the rodent brain, but also in the high-order brain of old-world primates8,9 and in …

Previous attempts to identify neuroprotective targets by studying the ischemic cascade and devising ways to suppress it have failed to translate to efficacious therapies for acute ischemic stroke. We hypothesized that studying the molecular determinants of endogenous neuroprotection in two well-established paradigms, the resistance of CA3 hippocampal neurons to global ischemia and the tolerance conferred by ischemic preconditioning (IPC), would reveal new neuroprotective targets. We found that the product of the tuberous sclerosis complex 1 gene (TSC1), hamartin, is selectively induced by ischemia in hippocampal CA3 neurons. In CA1 neurons, hamartin was unaffected by ischemia but was upregulated by IPC preceding ischemia, which protects the otherwise vulnerable CA1 cells. Suppression of hamartin expression with TSC1 shRNA viral vectors both in vitro and in vivo increased the vulnerability of neurons to cell death following oxygen glucose deprivation (OGD) and ischemia. In vivo, suppression of TSC1 expression increased locomotor activity and decreased habituation in a hippocampal-dependent task. Overexpression of hamartin increased resistance to OGD by inducing productive autophagy through an mTORC1-dependent mechanism. Copyright © 2013 Nature America, Inc.

In a 61-year-old woman with well controlled arterial hypertension, hypercholesterolemia, and smoke and suffering from recurrent angina pectoris despite angiographically normal epicardial coronary vessels and maximal therapy, the replacement of nitrates with novel antiangina drug ranolazine, after 6-month therapy, induced a complete relief of angina and a relevant rising of the transthoracic Doppler-derived coronary flow reserve (CFR). The present clinical case underlines therefore how in patients with chronic ischemic heart disease without epicardial coronary stenosis ranolazine can induce an improvement till the complete solution of the angina symptoms and a substantial increase of CFR as expression of the enhancement of the microvascular coronary function. The improvement of both symptoms and coronary microvascular function is strictly linked to the mechanism of action of the drug. Ranolazine induces in fact a reduction of the intracellular late sodium current that leads to a reduction of the intracellular calcium concentration thus producing a better myocardial diastolic relaxation process which in its turns enhances the myocardial perfusion. The ranolazine acts therefore as a lusitropic drug that improves the diastolic dysfunction and the segmental ischemia thus affecting one of the first steps of the ischemic cascade.

The precise manipulation of microcirculation in mice can facilitate mechanistic studies of brain injury and repair after ischemia, but this manipulation remains a technical challenge, particularly in conscious mice. We developed a technology that uses micromagnets to induce aggregation of magnetic nanoparticles to reversibly occlude blood flow in microvessels. This allowed induction of ischemia in a specific cortical region of conscious mice of any postnatal age, including perinatal and neonatal stages, with precise spatiotemporal control but without surgical intervention of the skull or artery. When combined with longitudinal live-imaging approaches, this technology facilitated the discovery of a feature of the ischemic cascade: selective loss of smooth muscle cells in juveniles but not adults shortly after onset of ischemia and during blood reperfusion.

The aim of this study was to explore the signaling and neuroprotective effect of transactivator of transcription (TAT) protein transduction of the apoptosis repressor with CARD (ARC) in in vitro and in vivo models of cerebral ischemia in mice. In mice, transient focal cerebral ischemia reduced endogenous ARC protein in neurons in the ischemic striatum at early reperfusion time points, and in primary neuronal cultures, RNA interference resulted in greater neuronal susceptibility to oxygen glucose deprivation (OGD). TAT.ARC protein delivery led to a dose-dependent better survival after OGD. Infarct sizes 72 h after 60 min middle cerebral artery occlusion (MCAo) were on average 30 ± 8% (mean ± SD; p = 0.005; T2-weighted MRI) smaller in TAT.ARC-treated mice (1 μg intraventricularly during MCAo) compared with controls. TAT.ARC-treated mice showed better performance in the pole test compared with TAT.β-Gal-treated controls. Importantly, post-stroke treatment (3 h after MCAo) was still effective in affording reduced lesion volume by 20 ± 7% (mean ± SD; p < 0.05) and better functional outcome compared with controls. Delayed treatment in mice subjected to 30 min MCAo led to sustained neuroprotection and functional behavior benefits for at least 28 d. Functionally, TAT.ARC treatment inhibited DAXX–ASK1–JNK signaling in the ischemic brain. ARC interacts with DAXX in a CARD-dependent manner to block DAXX trafficking and ASK1–JNK activation. Our work identifies for the first time ARC–DAXX binding to block ASK1–JNK activation as an ARC-specific endogenous mechanism that interferes with neuronal cell death and ischemic brain injury. Delayed delivery of TAT.ARC may present a promising target for stroke therapy., The Journal of Neuroscience, 36 (31), ISSN:0270-6474, ISSN:1529-2401

Inflammation plays a crucial role in the pathophysiology of acute ischemic stroke. In the ischemic cascade, resident microglia are rapidly activated in the brain parenchyma and subsequently trigger inflammatory mediator release, which facilitates leukocyte-endothelial cell interactions in inflammation. Activated leukocytes invade the endothelial cell junctions and destroy the blood-brain barrier integrity, leading to brain edema. Toll-like receptors (TLRs) stimulation in microglia/macrophages through the activation of intercellular signaling pathways secretes various proinflammatory cytokines and enzymes and then aggravates cerebral ischemic injury. The secreted cytokines activate the proinflammatory transcription factors, which subsequently regulate cytokine expression, leading to the amplification of the inflammatory response and exacerbation of the secondary brain injury. Traditional Chinese medicines (TCMs), including TCM-derived active compounds, Chinese herbs, and TCM formulations, exert neuroprotective effects against inflammatory responses by downregulating the following: ischemia-induced microglial activation, microglia/macrophage-mediated cytokine production, proinflammatory enzyme production, intercellular adhesion molecule-1, matrix metalloproteinases, TLR expression, and deleterious transcription factor activation. TCMs also aid in upregulating anti-inflammatory cytokine expression and neuroprotective transcription factor activation in the ischemic lesion in the inflammatory cascade during the acute phase of cerebral ischemia. Thus, TCMs exert potent anti-inflammatory properties in ischemic stroke and warrant further investigation.

Several neuroprotection strategies shown to be effective in animal models have failed to demonstrate efficacy in human stroke. The complexity of the molecular ischemic cascade is perhaps one of the most important reasons for this failure. Pharmaceutical approaches aimed at blocking individual molecular pathways have proved to be insufficient for the task. Pleiotropic drugs, on the other hand, acting at different levels of the ischemic cascade, seem to provide a more comprehensive attack based on the pathophysiology of cerebral ischemia. The mammalian target of rapamycin (mTOR) has emerged as a new potential therapeutic target. Based on its ability to modulate different processes of the ischemic cascade, mTOR may acquire the capability to limit ischemic neuronal death and promote neurological recovery. However, further knowledge about the intricate cellular signaling pathways of mTOR in cerebral ischemia is required in order to develop mTOR-reliant clinical strategies.

Stroke is the third leading cause of death, due to its high incidence, the severity of the insult, and lack of treatment options. The only therapeutic is restoration of cerebral blood flow achieved by recombinant tissue plasminogen activator treatment, but only approximately 5% of patients receive it. In addition, therapeutics aimed at achieving neuroprotection by blocking the ischemic cascade, as identified in numerous preclinical studies, failed in clinical trials. This failure in translation from experimental models to clinical trials led to a re-evaluation of properties which would constitute the ‘‘best-in class’’ therapeutics to be used against stroke. Given that neuroprotection appears ineffective per se, an emerging direction is to identify therapies, probably combinatorial in nature, which protect the whole neurovascular unit and target timedependent neurotoxic mechanisms. Molecules that activate complex cellular signaling cascades that render the brain resistant to subsequent ischemia, known as preconditioners, offer a novel perspective in stroke protection. Preconditioning elicits complex endogenous neuroprotective responses that act by pleiotropic mechanisms to block death pathways, promote survival pathways and increase resistance. In addition to chemical preconditioners, natural/endogenous compounds such as adenosine, glutamate, lysophospholipids, and omega-3 polyunsaturated fatty acids have been demonstrated to be excellent preconditioners. Consequently, a major new concept in preconditioning to combat stroke is introduced, which is preconditioning achieved through supplementation of an essential item in diet or as a nutraceutical. Several epidemiologic studies suggested a beneficial effect of a seafood/omega-3-enriched diet in cerebral diseases, but the omega-3-induced protective mechanisms are still poorly identified. This review highlights how α-linolenic acid (ALA), the omega-3 polyunsaturated fatty acid precursor, protects the brain from in vivo and in vitro models of stroke, thus potentially fulfilling the goal of identifying the ‘‘best-in class’’ therapeutics against stroke. Also described is the surprising pleiotric nature of ALA in protecting neurons, vasodilating brain arteries and stimulating neuroplasticity. Importantly, feasibility of delivery has been demonstrated, since ALA supplementation can be achieved through modification of the daily diet, for which prevention of stroke-induced mortality and cerebral damage has been confirmed. Therefore evaluating ALA as an interesting preconditioner against stroke represents a novel and extremely relevant concept in the context of nutraceutical and functional food development.

Immunity and inflammation are key elements of the pathobiology of stroke, a devastating illness second only to cardiac ischemia as a cause of death worldwide. The immune system participates in the brain damage produced by ischemia, and the damaged brain, in turn, exerts an immunosuppressive effect that promotes fatal infections that threaten the survival of people after stroke. Inflammatory signaling is involved in all stages of the ischemic cascade, from the early damaging events triggered by arterial occlusion to the late regenerative processes underlying post-ischemic tissue repair. Recent developments have revealed that stroke engages both innate and adaptive immunity. But adaptive immunity triggered by newly exposed brain antigens does not have an impact on the acute phase of the damage. Nevertheless, modulation of adaptive immunity exerts a remarkable protective effect on the ischemic brain and offers the prospect of new stroke therapies. As immunomodulation is not devoid of deleterious side effects, a better understanding of the reciprocal interaction between the immune system and the ischemic brain is essential to harness the full therapeutic potential of the immunology of stroke.

ObjectivesThe aim of this study was to determine the prognostic value of assessing left atrial function during dobutamine stress testing.BackgroundLeft ventricular diastolic dysfunction precedes systolic wall motion abnormalities in the ischemic cascade. Severity of left ventricular diastolic function during cardiac stress is not characterized well by current clinical imaging protocols but may be an important prognostic factor. We hypothesized that abnormal early left atrial emptying measured during dobutamine stress cardiac magnetic resonance will reflect these diastolic changes and may be associated with cardiovascular outcomes.MethodsWe enrolled 122 consecutive patients referred for dobutamine stress cardiac magnetic resonance for suspected myocardial ischemia. Left atrial volumes were retrospectively measured by the biplane area-length method at left ventricular end-systole (VOLmax) and before atrial contraction (VOLbac). Left atrial passive emptying fraction defined by (VOLmax – VOLbac) × 100%/VOLmax and the absolute percent increase in left atrial passive emptying fraction during dobutamine stress (ΔLAPEF) were quantified.ResultsTwenty-nine major adverse cardiac events (MACE) occurred during follow-up (median 23 months). By Kaplan-Meier analysis, patients with ΔLAPEF 10.8 (p = 0.004). By univariable analysis, ΔLAPEF was strongly associated with MACE (unadjusted hazard ratio for every 10% decrease = 1.56, p < 0.005). By multivariable analysis, every 10% decrease in ΔLAPEF carried a 57% increase in MACE, after adjustment to presence of myocardial ischemia and infarction.ConclusionsReduced augmentation of left atrial passive emptying fraction during dobutamine stress demonstrated strong association with MACE. We speculate that reduced left atrial passive emptying reserve during inotropic stress may represent underlying diastolic dysfunction and warrants further investigation.

Current views of the pathophysiology of transient ischemic attacks (TIA) are based on the concept of focal cerebral ischemic brain lesions [1‐6]. Many aspects of transient focal cerebral ischemia have been studied both in carefully controlled experimental conditions and in clinical studies. At the same time, detailed pathophysiological characterization of reversible focal ischemic brain lesions represents a very complex problem. In clinical studies on patients, this is restricted by a multitude of factors which are difficult to control: the difficulty of identifying accurately the time of onset of ischemia, the heterogeneity of patients in terms of age, gender, and genetic differences, etc. Serious difficulties occur on comparison of clinical and experimental data because of anatomical, pathophysiological, genetic, and other differences between people and laboratory animals [3, 5, 7‐10]. One major point in the concept of focal cerebral ischemic brain lesions is the “ischemic cascade,” which is a chain of complex molecular genetic and biochemical derangements in brain cells occurring in response to decreases in local cerebral blood flow (CBF) which, in certain conditions, ends with irreversible structural brain damage [1, 3, 5, 11]. The sequence of steps in the “ischemic cascade” has been established: 1) a decrease in brain blood flow; 2) glutamate excitotoxicity; 3) intracellular accumulation of calcium; 4) activation of intracellular enzymes; 5) increases in nitric oxide synthesis and development of oxidant stress; 6) expression of early response genes; 7) the long-term effects of ischemia (local inflammatory reactions, microvascular lesions, damage to the blood-brain barrier); 8) apoptosis [1, 11]. The time framework of the occurrence of the steps in the “ischemic cycle” have been identified: energy deficiency in ischemic tissue occurs in the first three hours, glutamate excitotoxity occurs at 3‐6 h, and impairments to calcium homeostasis and lactate acidosis occur at one day. The long-term effects of ischemia start 2‐3 h from the onset of ischemia and reach a maximum at 12‐36 h (oxidative stress, local inflammation) and 2‐3 days (apoptosis), but persist for long periods (several months) [1, 11].

Stroke is a serious neurological disease, and constitutes a major cause of death and disability throughout the world. The pathophysiology of stroke is complex, and involves excitotoxicity mechanisms, inflammatory pathways, oxidative damage, ionic imbalances, apoptosis, angiogenesis and neuroprotection. The ultimate result of ischemic cascade initiated by acute stroke is neuronal death along with an irreversible loss of neuronal function. Therapeutic strategies in stroke have been developed with two main aims: restoration of cerebral flow and the minimization of the deleterious effects of ischemia on neurons. Intense research spanning over the last two decades has witnessed significant therapeutic advances in the form of carotid endarterectomy, thrombolytics, anticoagulant therapy, antiplatelet agents, neuroprotective agents, and treating associated risk factors such as hypertension and hyperlipidemia. However, the search for an effective neuroprotectant remains frustrating, and the current therapeutic protocols remain suboptimal. Till date only one FDA-approved drug is available for ischemic stroke; i.e., the serine protease tissue-type plasminogen activator (tPA), utility of which is limited by short therapeutic window. The objective of this review is to critically evaluate the major mechanisms underlying stroke pathophysiology, with emphasis on potential novel targets for designing newer therapeutic modalities.

The general failure of neuroprotectants in clinical trials of ischemic stroke points to the possibility of a fundamental blind spot in the current conception of ischemic brain injury, the “ischemic cascade”. This is the second in a series of four papers whose purpose is to work towards a revision of the concept of brain ischemia by applying network concepts to develop a bistable model of brain ischemia. We here build the bistable network model of brain ischemia. The central concept is that of a post-ischemic state space. Ischemia, as a quantitative perturbation, is envisioned to push the brain through a series of four phenotypes as a function of the amount of ischemia: the homeostatic, preconditioned, delayed neuronal death and necrotic phenotypes. The phenotypes are meta-stable attractors in the landscape of the post-ischemic state space. The sequence of the phenotypes derives from the mutual antagonism between damage mechanisms and stress responses, each conceived as aggregate ensemble variables. The competition between damage mechanisms and stress responses is posited to have the form of a bistability. Application of bistability to brain ischemia is grounded in the incontrovertible fact that post-ischemic neurons face the mutually exclusive decision to either live or die.

Combined 2-MHz ultrasound (US) and second-generation, sulfur hexafluoride microbubbles (MB) treatment (US+MB) was performed in a permanent middle cerebral artery (MCA) occlusion model in rats to evaluate possible effects on the ischemic cascade. We used 16 Wistar rats and the MCA occlusion model for stroke induction. Glutamate, pyruvate, lactate and glycerol levels were measured by intracerebral microdialysis before and after stroke induction and after US+MB application (n = 8) for 20 h. After 24 h, brain infarct volume, apoptosis and IL-6 and TNF-alpha levels were evaluated. The infarct volume was significantly reduced (p < 0.05) in the US+MB-treated group compared with control animals. In additional, glutamate levels were significantly lower in US+MB-treated animals, and these animals showed a higher rate of apoptotic cell death in the infarcted area. The levels of IL-6 and TNF-alpha concentrations were not different in both groups, and there was no apoptotic cell death outside the infarction in animals treated with US+MB. The results demonstrate that US+MB with second generation microbubbles does not have a harmful effect on ischemic stroke in an MCA occlusion model of the rat.

Bis(7)-tacrine, a promising anti-Alzheimer's dimer, has been shown to have multiple neuroprotective activities in vitro. Here, we investigate whether bis(7)-tacrine attenuates focal cerebral ischemic impairment in vivo. Cerebral ischemia was induced in Sprague-Dawley rats by transient (2 h) middle cerebral artery occlusion (MCAO) followed by 24h of reperfusion. Bis(7)-tacrine administered intraperitoneally 15 min after ischemia dose-dependently improved neurological behavior deficits and reduced both cerebral infarct volume and edema. The TUNEL staining assay showed that bis(7)-tacrine attenuated neuronal apoptosis in the penumbral region. Compared with that for memantine, a moderately effective N-methyl-D-aspartate (NMDA) receptor antagonist with a similar affinity and potency to bis(7)-tacrine in blocking NMDA receptors, the therapeutic window for bis(7)-tacrine was wider and lasted up to 6 h after the onset of ischemia. Bis(7)-tacrine did not affect physiological parameters or regional cerebral blood flow during either the occlusion period or the early reperfusion stage. In conclusion, bis(7)-tacrine close- and time-dependently protected against acute focal cerebral ischemic insults, possibly through the drug's anti-apoptotic effects during multiple events in the ischemic cascade. (C) 2008 Elsevier Ireland Ltd. All rights reserved.

During cerebral ischemic cascade, a unifying factor which leads to mitochondrial dysfunctions is lack of oxygen followed by decrease in ATP production. The present study demonstrates the effect of selenium pretreatment (0.1 mg/kg as sodium selenite, i.p, 7 days) on cerebral ischemia-induced altered levels of mitochondrial ATP content, intracellular calcium (Ca(i)(2+)) in synaptosomes, expression of heat stress protein (Hsp70) and caspase-3 activity in hippocampus followed by neurobehavioral deficits and histopathological changes in Wistar rats. Cerebral ischemia was induced for 2 h followed by reperfusion for 22 h. It was observed that levels of (Ca(i)(2+)), Hsp70 and caspase-3 activity were significantly (p

ObjectivesIn order to more clearly understand the electrocardiographic manifestations of early transmural ischemia, we studied electrocardiograms (ECGs) in patients undergoing balloon angioplasty.BackgroundDecisions regarding reperfusion strategies in patients with acute myocardial infarction rely largely on the presence of ST-segment elevation (STE) in the ECG, consequently with significant limitations. Studies of the “ischemic cascade” show that ST-segment changes occur well after the onset of wall motion abnormalities.MethodsWe prospectively analyzed ECGs obtained at 20-s intervals in 74 patients undergoing elective balloon angioplasty. The ECGs were analyzed using 3 methodologies. In 74 patients, the ST-segment, the T-wave, and the QT-interval were analyzed using the MUSE (General Electric HC, Menomonee Falls, Wisconsin) automated system (MUSE). Fifty patients were also analyzed using the Interval Editor automated system (IE; General Electric HC). In 20 patients, measurements were made manually.ResultsTransmural ischemia prolonged the QTc interval (using the Bazett’s formula) in 100% of patients. In all 74 patients analyzed with MUSE, QTc interval prolonged from 423 ± 25 ms to 455 ± 34 ms (p < 0.001). In the 50 patients analyzed with IE, QTc interval prolonged in 50 of 50 (100%) patients (from 424 ± 27 ms to 458 ± 33 ms [p < 0.001]). Mean time to maximal QTc interval prolongation, changes in T-wave polarity, ≥1 mm STE, and ST-segment depression (STD) were 22, 24, 29, and 35 s, respectively. Although QTc interval prolonged in 100% of patients, T-wave changes, STE, and STD (≥1 mm) occurred in 7%, 15%, and 7%, respectively.ConclusionsThe QTc interval prolongs in 100% of patients with early transmural ischemia. When compared with clinically accepted indexes of transmural ischemia (i.e., STD and STE [≥1 mm]) it is the earliest ECG abnormality.

The brain consumes an enormous amount of energy (20%) that is disproportionate to its small size (2%). It relies on the constant delivery of oxygen and glucose to produce adenosine triphosphate, the cellular energy unit required to maintain brain cells’ functioning. Even brief loss of blood flow as a result of blockage or rupture of a cerebral blood vessel, called ischemia, leads to a sudden appearance of neurological symptoms. Stroke usually affects only one side of the brain, and the perfusion field of the affected blood vessel defines the specific pattern of sensory or motor symptoms produced. In a minority of patients (10%) blood flow is disrupted because of a vessel rupture, causing a hemorrhagic stroke. The vast majority of patients have vessel blockage as a consequence of atherosclerotic plaque, narrowing cerebral blood vessels, or distant plaque, giving rise to floating fragments called emboli that can lodge in cerebral blood vessels. The most effective treatment for stroke involves the rapid opening of an occluded vessel either mechanically or using tissue plasminogen activator (tPA), a clot-busting chemical. Time is of the essence because neurons die quickly in the absence of blood flow and tPA becomes almost ineffective 3 h after a stroke. The cellular and molecular processes underlying the ischemic cascade that culminates in neuronal cell death are well understood, particularly the importance of the excitatory neurotransmitter glutamate (Glu), which is elevated to toxic concentrations after stroke. Its binding to neuronal Glu receptors triggers a process called excitotoxicity, which causes rapid necrotic and slow apoptotic neuronal death. Approximately 800,000 new stroke cases are diagnosed annually in the United States and 200,000 patients die from it. In spite of excellent poststroke physical and occupational therapy, many of the 4 million stroke survivors live with permanent disability at a huge cost to the individual, their families, and society.

This review article discusses the historical origin of cardiac radionuclide-based methods, the physiologic background that justifies their existence, as well as the basic pathophysiologic concepts of coronary artery disease and their connection with the technologic design and application of these methods. Most importantly, this review discusses the important insights that these methods have provided to the understanding of the mechanisms of ischemia, risk stratification, and both treatment choice and treatment efficacy in ischemic heart disease. Nuclear cardiology originated as an attempt to provide complementary physiologic information to the anatomic information provided by coronary angiography. To comprehend the design and applications of nuclear cardiology methods, one must have a basic understanding of coronary artery disease as an inflammatory process that may manifest as acute or chronic states. Basic concepts on myocyte metabolic pathways, coronary blood flow, ischemic cascade, ventricular remodeling, and ejection fraction become critical for this purpose. Insights into risk stratification may permit patient-tailored therapy approaches. Insights into prognosis have made nuclear cardiology a robust tool for outcome predictions, with an exceptionally high negative predictive value. Evaluation of prognosis in special patient populations such as diabetics has originated important pathophysiologic concepts. Most insights into phenomena such as myocardial hibernation, myocardial stunning, and viability have been generated by nuclear cardiology techniques. Finally, new applications of radionuclide-based methods such as molecular identification of “vulnerable” atherosclerotic plaques, “ischemic memory” using fatty acid imaging, and myocardial innervation imaging provide new avenues for insightful research.

The initial response to an ischemic event is the rapid release of excitatory amino acid's followed by the activation of the "ischemic cascade". It has been suggested that neurosteroids, which act as negative modulators of excitatory amino acid receptors, may improve behavioral functions and promote neuronal survival following ischemia. The present study evaluated the pharmacological effects of 3-alpha-ol-5-beta-pregnan-20-one hemisuccinate (ABHS), a neurosteroid that inhibits excitatory amino acid receptor function, in a rabbit reversible spinal cord ischemia model (RSCIM). ABHS was administered (25 mg/kg) intravenously (i.v.) 5 or 30 min following the start of occlusion to groups of rabbits exposed to ischemia induced by temporary occlusion of the infrarenal aorta. The group P50 represents the duration of ischemia (min) associated with a 50% probability of resultant permanent paraplegia. Quantal analysis indicated that the P50 of the control group was 23.44 +/- 4.32 min. Using the RSCIM, neuroprotection is observed if a drug significantly prolongs the P50 compared to the control group. Treatment with ABHS (25 mg/kg) 5 min post-occlusion significantly (p0.05) prolonged the P50 of the group to 49.18 +/- 10.44 min, an increase of 110%. The effect of ABHS was not durable following a single injection since a significant difference between the control and ABHS-treated groups was not measurable at 48 h. However, if ABHS was injected 5 min following the start of ischemia and again 24 h after ischemia, there was a persistent effect of the drug at 48 h. Moreover, ABHS also increased the tolerance to ischemia if administered 30 min following the start of occlusion. Our results suggest that neuroactive steroids such as ABHS, which are selective NMDA receptor antagonists, may have substantial therapeutic benefit for the treatment of ischemic injuries including spinal cord neurodegeneration and stroke.

Experimental studies have postulated the ischemic cascade and the present study was designed to elucidate whether it can be observed in the clinical setting. Fifty-three patients suspected of having coronary artery disease were studied. Myocardial perfusion abnormalities (MPA) and wall motion abnormalities (WMA) were assessed simultaneously by infusion of Levovist during dobutamine stress echocardiography. Time - intensity data of myocardial opacification were fitted for Y=A (1-e-β t) from which the rate of increase (β) of intensity were derived both at rest and during stress. Wall motion was also given a score. Bright opacification was observed in 50 patients: 25 showed significant stenosis (>50%) in the left anterior descending artery (group II) on coronary angiography and 25 did not (group I). Significant differences were found in the β ratio (stress/rest) between the 2 groups at a low-dose (2.0±0.3 vs 1.5±0.5, p

Background — We hypothesized that during demand ischemia, abnormal perfusion will precede abnormal function, the spatial extent of perfusion abnormality will be greater than that of functional abnormality, and the spatiotemporal disparity between abnormal perfusion and abnormal function will be more marked in the presence of single-vessel stenosis (SVS) versus multivessel stenosis (MVS). Methods and Results — Nine dogs each underwent either SVS or MVS placement. These noncritical stenoses were classified as mild, moderate, or severe on the basis of the transstenotic pressure gradient (10 to 14, 15 to 20, or >20 mm Hg). Dobutamine was infused starting at 10 and reaching 40 μg/kg −1 · min −1 . Wall thickening (WT) and myocardial perfusion (myocardial contrast echocardiography) were assessed at each stage. Resting perfusion and function were normal in all dogs. In SVS, abnormal perfusion (delayed rate of microbubble replenishment) was seen at the lowest dose of dobutamine irrespective of the stenosis severity, whereas WT abnormality was seen only at high doses of dobutamine and was influenced by the stenosis severity. The spatial extent of abnormal perfusion exceeded that of WT abnormality at all but the highest dobutamine dose. This spatiotemporal discordance between abnormal perfusion and function was significantly less in MVS, where it was possible to identify separate regions with abnormal function at lower doses of dobutamine. Conclusions — These data support the occurrence of the ischemic cascade during demand ischemia. They also explain the higher sensitivity of abnormal perfusion compared with abnormal function for the detection of coronary stenosis as well as the higher sensitivity of dobutamine echocardiography for MVS compared with SVS.

Stroke is among the most common diseases of advanced age and is becoming a steadily increasing financial healthcare problem in the industrialized world with the increasing longevity and aging of the population. The incidence of ischemic stroke is highest in the elderly population, representing one of the most common causes of disability and mortality worldwide. Over the past decades, a tremendous amount of research has been undertaken into developing effective therapeutic strategies for the treatment of acute stroke. Unfortunately, many neuroprotective agents that have shown successful results in treating animal models of acute stroke have failed to translate into clinical treatments. Only tissue plasminogen activator is currently licensed for use in the treatment of acute ischemic stroke. Increasing evidence shows that the central nervous system and the immune system interact in complex ways, and better insight into these interactions may be relevant to the treatment of patients with stroke and other forms of central nervous system injury. However, during recent years, promising findings suggest that systemic inflammation and neuroinflammation are central features in cerebrovascular disease. Atherosclerosis, autoimmune disease, and physiological stressors, such as infection or surgery, may be a risk factor for the initial development of cerebral ischemia. In addition, the immune system actively participates in the pathophysiological processes occurring during an ischemic stroke. Thrombosis and hypoxia trigger an intravascular inflammatory cascade which elicits an inflammatory response in the injured brain that is accompanied by a marked local inflammatory reaction that is initiated by ischemia- or hematoma-induced expression of cytokines, adhesion molecules, and other inflammatory mediators, including prostanoids, extracellular proteases, reactive oxygen species, and nitric oxide, leading to the accumulation of inflammatory cells, such as leukocytes and microglia, which is further augmented by the innate immune response to cellular damage occurring in the parenchyma. Many of these compounds are known to promote and sustain inflammatory responses at local and systemic level, producing a neuroinflammatory response and a systemic acute-phase response. The acute-phase inflammatory response after stroke is a reflection of an unspecific systemic inflammatory response syndrome. Classic acute-phase reactants and body temperature are also modified in stroke and may be useful in the prediction of events and outcome and as therapeutic targets. The activation of innate immunity after stroke sets the stage for an adaptive immune response directed against brain antigens. The pathogenic significance of adaptive immunity and its long-term effects on the postischemic brain remains unclear, but it cannot be ruled out that a persistent autoimmune response to brain antigens has deleterious and long-lasting consequences, such as the development of poststroke dementia. This immune activation causes secondary tissue injury, but it is unclear whether modulating the acute immune response to stroke can produce clinical benefits. Better understanding of the role of the postischemic-induced inflammatory response and its potential for modulation might have profound implications for patient treatment. Preclinical studies suggest that interventions that are aimed at attenuating such inflammation reduce the progression of brain damage that occurs during the late stages of cerebral ischemia. In particular, strategies that block the activity of inflammation-related enzymes reduce ischemic damage with an extended therapeutic window. Although, clinical trials using anti-inflammatory strategies did not show benefit in patients with ischemic stroke, there is a strong rationale for continuing to explore the efficacy of anti-inflammatory therapies in the treatment of the late stages of cerebral ischemia acting more on the modulation of these later events than targeting of specific steps in the ischemic cascade.

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