Delayed tPA Treatment Research Articles

Interferon-β modulates microglial polarization to ameliorate delayed tPA-exacerbated brain injury in ischemic stroke.

Tissue plasminogen activator (tPA) is the only FDA-approved drug for the treatment of ischemic stroke. Delayed tPA administration is associated with increased risks of blood-brain barrier (BBB) disruption and hemorrhagic transformation. Studies have shown that interferon beta (IFNβ) or type I IFN receptor (IFNAR1) signaling confers protection against ischemic stroke in preclinical models. In addition, we have previously demonstrated that IFNβ can be co-administered with tPA to alleviate delayed tPA-induced adverse effects in ischemic stroke. In this study, we investigated the time limit of IFNβ treatment on the extension of tPA therapeutic window and assessed the effect of IFNβ on modulating microglia (MG) phenotypes in ischemic stroke with delayed tPA treatment. Mice were subjected to 40 minutes transient middle cerebral artery occlusion (MCAO) followed by delayed tPA treatment in the presence or absence of IFNβ at 3h, 4.5h or 6h post-reperfusion. In addition, mice with MG-specific IFNAR1 knockdown were generated to validate the effects of IFNβ on modulating MG phenotypes, ameliorating brain injury, and lessening BBB disruption in delayed tPA-treated MCAO mice. Our results showed that IFNβ extended tPA therapeutic window to 4.5h post-reperfusion in MCAO mice, and that was accompanied with attenuated brain injury and lessened BBB disruption. Mechanistically, our findings revealed that IFNβ modulated MG polarization, leading to the suppression of inflammatory MG and the promotion of anti-inflammatory MG, in delayed tPA-treated MCAO mice. Notably, these effects were abolished in MG-specific IFNAR1 knockdown MCAO mice. Furthermore, the protective effect of IFNβ on the amelioration of delayed tPA-exacerbated ischemic brain injury was also abolished in these mice. Finally, we identified that IFNβ-mediated modulation of MG phenotypes played a role in maintaining BBB integrity, because the knockdown of IFNAR1 in MG partly reversed the protective effect of IFNβ on lessening BBB disruption in delayed tPA-treated MCAO mice. In summary, our study reveals a novel function of IFNβ in modulating MG phenotypes, and that may subsequently confer protection against delayed tPA-exacerbated brain injury in ischemic stroke.

QiShenYiQi Inhibits Tissue Plasminogen Activator-Induced Brain Edema and Hemorrhage after Ischemic Stroke in Mice.

Background: Thrombolysis with tissue plasminogen activator (tPA) remains the only approved drug therapy for acute ischemic stroke. However, delayed tPA treatment is associated with an increased risk of brain hemorrhage. In this study, we assessed whether QiShenYiQi (QSYQ), a compound Chinese medicine, can attenuate tPA-induced brain edema and hemorrhage in an experimental stroke model. Methods: Male mice were subjected to ferric chloride-induced carotid artery thrombosis followed by mechanical detachment of thrombi. Then mice were treated with QSYQ at 2.5 h followed by administration of tPA (10 mg/kg) at 4.5 h. Hemorrhage, infarct size, neurological score, cerebral blood flow, Evans blue extravasation, FITC-labeled albumin leakage, tight and adherens junction proteins expression, basement membrane proteins expression, matrix metalloproteinases (MMPs) expression, leukocyte adhesion, and leukocyte infiltration were assessed 24 h after tPA administration. Results: Compared with tPA alone treatments, the combination therapy of QSYQ and tPA significantly reduced hemorrhage, infarction, brain edema, Evans blue extravasation, albumin leakage, leukocyte adhesion, MMP-9 expression, and leukocyte infiltration at 28.5 h after stroke. The combination also significantly improved the survival rate, cerebral blood flow, tight and adherens junction proteins (occludin, claudin-5, junctional adhesion molecule-1, zonula occludens-1, VE-cadherin, α-catenin, β-catenin) expression, and basement membrane proteins (collagen IV, laminin) expression. Addition of QSYQ protected the downregulated ATP 5D and upregulated p-Src and Caveolin-1 after tPA treatment. Conclusion: Our results show that QSYQ inhibits tPA-induced brain edema and hemorrhage by protecting the blood-brain barrier integrity, which was partly attributable to restoration of energy metabolism, protection of inflammation and Src/Caveolin signaling activation. The present study supports QSYQ as an effective adjunctive therapy to increase the safety of delayed tPA thrombolysis for ischemic stroke.

Interferon-β alleviates delayed tPA-induced adverse effects via modulation of MMP3/9 production in ischemic stroke

AbstractTissue plasminogen activator (tPA) is the only US Food and Drug Administration (FDA)–approved drug for ischemic stroke. However, delayed tPA administration is associated with increased risk of blood-brain barrier (BBB) disruption and hemorrhagic transformation (HT). Interferon-β (IFNβ), an FDA-approved drug for the treatment of multiple sclerosis, is a cytokine with immunomodulatory properties. Previous studies, including ours, demonstrated that IFNβ or type I IFN receptor signaling conferred protection against ischemic stroke in preclinical models, suggesting IFNβ might have translational therapeutic potential for the treatment of ischemic stroke. Currently, whether IFNβ could be coadministered with tPA to alleviate delayed tPA-induced adverse effects remains unknown. To elucidate that, IFNβ was coadministered with delayed tPA to ischemic stroke animals, and the severity and pathology of ischemic brain injury were assessed. We found delayed tPA treatment exacerbated ischemic brain injury, manifested by aggravated BBB disruption and HT. Notably, IFNβ ameliorated delayed tPA–exacerbated brain injury and alleviated adverse effects. Mechanistic studies revealed IFNβ suppressed tPA-enhanced neuroinflammation and MMP3/9 production in the ischemic brain. Furthermore, we identified IFNβ suppressed MMP9 production in microglia and attenuated tight junction protein degradation in brain endothelial cells. Moreover, we observed that peripheral immune cells may participate to a lesser extent in delayed tPA–exacerbated brain injury during the early phase of ischemic stroke. In conclusion, we provide the first evidence that IFNβ can be coadministered with tPA to mitigate delayed tPA–induced adverse effects of BBB disruption and HT that could potentially extend the tPA therapeutic window for the treatment of ischemic stroke.

Human neural stem cells improve early stage stroke outcome in delayed tissue plasminogen activator-treated aged stroke brains

IntroductionClinically, significant stroke injury results from ischemia-reperfusion (IR), which induces a deleterious biphasic opening of the blood-brain barrier (BBB). Tissue plasminogen activator (tPA) remains the sole pharmacological agent to treat ischemic stroke. However, major limitations of tPA treatment include a narrow effective therapeutic window of 4.5 h in most patients after initial stroke onset and off-target non-thrombolytic effects (e.g., the risk of increased IR injury). We hypothesized that ameliorating BBB damage with exogenous human neural stem cells (hNSCs) would improve stroke outcome to a greater extent than treatment with delayed tPA alone in aged stroke mice. MethodsWe employed middle cerebral artery occlusion to produce focal ischemia with subsequent reperfusion (MCAO/R) in aged mice and administered tPA at a delayed time point (6 h post-stroke) via tail vein. We transplanted hNSCs intracranially in the subacute phase of stroke (24 h post-stroke). We assessed the outcomes of hNSC transplantation on pathophysiological markers of stroke 48 h post-stroke (24 h post-transplant). ResultsDelayed tPA treatment resulted in more extensive BBB damage and inflammation relative to MCAO controls. Notably, transplantation of hNSCs ameliorated delayed tPA-induced escalated stroke damage; decreased expression of proinflammatory factors (tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-6), decreased the level of matrix metalloprotease-9 (MMP-9), increased the level of brain-derived neurotrophic factor (BDNF), and reduced BBB damage. ConclusionsAged stroke mice that received delayed tPA treatment in combination with hNSC transplantation exhibited reduced stroke pathophysiology in comparison to non-transplanted stroke mice with delayed tPA. This suggests that hNSC transplantation may synergize with already existing stroke therapies to benefit a larger stroke patient population.

Rosiglitazone ameliorates tissue plasminogen activator‐induced brain hemorrhage after stroke

ObjectiveDelayed thrombolytic therapy with recombinant tissue plasminogen activator (tPA) may exacerbate blood‐brain barrier (BBB) breakdown after ischemic stroke and lead to catastrophic hemorrhagic transformation (HT). Rosiglitazone(RSG), a widely used antidiabetic drug that activates peroxisome proliferator‐activated receptor‐γ (PPAR‐γ), has been shown to protect against cerebral ischemia through promoting poststroke microglial polarization toward the beneficial anti‐inflammatory phenotype. However, whether RSG can alleviate HT after delayed tPA treatment remains unknown. In this study, we sort to examine the role of RSG on tPA‐induced HT after stroke.Methods and resultsWe used the murine suture middle cerebral artery occlusion (MCAO) models of stroke followed by delayed administration of tPA (10 mg/kg, 2 hours after suture occlusion) to investigate the therapeutic potential of RSG against tPA‐induced HT. When RSG(6 mg/kg) was intraperitoneally administered 1 hour before MCAO in tPA‐treated MCAO mice, HT in the ischemic territory was significantly attenuated 1 day after stroke. In the tPA‐treated MCAO mice, we found RSG significantly mitigated BBB disruption and hemorrhage development compared to tPA‐alone‐treated stroke mice. Using flow cytometry and immunostaining, we confirmed that the expression of CD206 was significantly upregulated while the expression of iNOS was down‐regulated in microglia of the RSG‐treated mice. We further found that the expression of Arg‐1 was also upregulated in those tPA and RSG‐treated stroke mice and the protection against tPA‐induced HT and BBB disruption in these mice were abolished in the presence of PPAR‐γ antagonist GW9662 (4 mg/kg, 1 hour before dMCAO through intraperitoneal injection).ConclusionsRSG treatment protects against BBB damage and ameliorates HT in delayed tPA‐treated stroke mice by activating PPAR‐γ and favoring microglial polarization toward anti‐inflammatory phenotype.

INF-β treatment to prolong t-PA treatment window in cerebral ischemia

Background and Hypothesis: Cerebral ischemia is the 2nd leading cause of death worldwide. The pathological hallmarks of cerebral ischemia are cell damage, degradation of the blood brain barrier (BBB), and inflammation followed by resident microglia activation, peripheral immune cell infiltration and subsequent secondary neurodegeneration. The first line therapy for ischemic stroke is the thrombolytic, tPA. However, only ten percent of patients are eligible for this treatment – primarily due to the risk of cerebral hemorrhage, secondary to BBB breakdown. Less than ten percent of individuals with acute cerebral ischemia are eligible for tPA. The objective of this study is to establish whether matrix metalloproteinase (MMP) activity, implicated in exacerbating the cerebral infarct volume seen with delayed tPA treatment, can be suppressed with Interferon-β (IFN-β) and thus extend the therapeutic window of tPA.
 Experimental Design: We first investigated the therapeutic effect of IFN-β co-administered with t-PA in the mouse model of transient middle cerebral artery occlusion/reperfusion. Second, using immunoblotting technique we investigated the expression levels of MMPs in brain endothelial and microglial cells following various treatment combinations of TNFα and PGE2, t-PA, and INF-β.
 Results: First, we demonstrated that IFN-β coadministered with tPA reduces the infarct size in ischemic brains. Second, we demonstrated in microglial cells that MMP-9 expression induced by TNFα, PGE2, and tPA can be suppressed by IFN-β treatment. Our experiments to demonstrate the expression levels of MMP-3 and MMP-9 in brain endothelial cells require further optimization.
 Conclusion and Potential Impact: Overall these data indicate that IFN-β treatment is a viable therapeutic candidate to suppress the deleterious effects seen in delayed tPA treatment in the setting of acute cerebral ischemia. Furthermore, our preliminary data indicate that the molecular target of IFN-β, in this setting, belong to the MMP family of proteins.

TPA Helpers in the Treatment of Acute Ischemic Stroke: Are They Ready for Clinical Use?

Tissue plasminogen activator (tPA) is the only therapeutic agent approved to treat patients with acute ischemic stroke. The clinical benefits of tPA manifest when the agent is administered within 4.5 hours of stroke onset. However, tPA administration, especially delayed administration, is associated with increased intracranial hemorrhage (ICH), hemorrhagic transformation (HT), and mortality. In the ischemic brain, vascular remodeling factors are upregulated and microvascular structures are destabilized. These factors disrupt the blood brain barrier (BBB). Delayed recanalization of the vessels in the presence of relatively matured infarction appears to damage the BBB, resulting in HT or ICH, also known as reperfusion injury. Moreover, tPA itself activates matrix metalloproteases, further aggravating BBB disruption. Therefore, attenuation of edema, HT, or ICH after tPA treatment is an important therapeutic strategy that may enable clinicians to extend therapeutic time and increase the probability of excellent outcomes. Recently, numerous agents with various mechanisms have been developed to interfere with various steps of ischemia/ reperfusion injuries or BBB destabilization. These agents successfully reduce infarct volume and decrease the incidence of ICH and HT after delayed tPA treatment in various animal stroke models. However, only some have entered into clinical trials; the results have been intriguing yet unsatisfactory. In this narrative review, I describe such drugs and discuss the problems and future directions. These “tPA helpers” may be clinically used in the future to increase the efficacy of tPA in patients with acute ischemic stroke.

Salidroside improves brain ischemic injury by activating PI3K/Akt pathway and reduces complications induced by delayed tPA treatment

Cerebral ischemia causes blood-brain barrier (BBB) injury and thus increases the risk of complications secondary to thrombolysis, which limited its clinical application. This study aims to clarify the role and mechanism of salidroside (SALD) in alleviating brain ischemic injury and whether pretreatment of it could improve prognosis of delayed treatment of tissue plasminogen activator (t-PA). Rats were subjected to 3 h of middle cerebral artery occlusion (MCAO) and were intraperitoneally administered with 10, 20 or 40 mg/kg SALD before ischemia. 1.5% 5-triphenyl-2H-tetrazolium chloride (TTC) staining and neurological studies were performed to observe the effectiveness of SALD. The expressions and the distribution of phosphoinositide-3-kinase/protein kinase B (PI3K/Akt) signaling were analyzed. Experiments were further conducted in isolated microvessels and human brain microvascular endothelial cells (HBMECs) to explore the protective mechanism of SALD. Finally, rats were subjected to 6 h of MCAO and 24 h of reperfusion. tPA was given with or without the pretreatment of SALD. Various approaches including gelatin zymography, western blot and immunofluorescence were used to evaluate the effect of this combination therapy. SALD could reduce cerebral ischemic injury and enhance HBMECs viability subjected to OGD. In vivo and in vitro studies showed the mechanism might be related to the activation of PI3K/Akt signaling by phosphorylating Akt on Ser473. Pretreatment of SALD could alleviate BBB injury and improve the outcome of delayed treatment of tPA. These results provide evidence that SALD might be an effective adjuvant to reduce the complications induced by delayed tPA treatment for brain ischemia.

Abstract TP407: Combination of Minocycline and Neural Stem Cells Ameliorates Neurological Deficit in Aged Stroke Mice With Delayed Tpa Treatment

The great promise of using stem cells to treat stroke has been inhibited by challenges to stem cell survival in the toxic environment of post-stroke tissue. Reperfusion (removal of clot) can be achieved mechanically (thrombectomy, <6-8hrs or by tissue plasminogen activator (tPA, <4.5 hrs), but ischemia/reperfusion injury limits the treatment time window. Furthermore, deleterious non-thrombolytic off-target effects of delayed tPA infusion (e.g., >4.5hrs) have been shown within brain parenchyma, increasing vascular injury and death of neurons. Previously, we reported that human neural stem cell (hNSC) transplantation 24hrs after stroke shows multiple beneficial short-term effects within 48hrs post-stroke, reducing inflammation, blood-brain barrier (BBB) damage, and infarct size. Since delayed tPA administration exacerbates BBB damage and increases hemorrhage, we reasoned that ameliorating inflammation and BBB damage by pretreating with neuroprotectants (i.e., minocycline) prior to tPA might synergize to expand the time window for tPA and provide a better environment for NSC survival, thus increasing NSC efficacy. We utilized the middle cerebral artery occlusion stroke mouse model to induce focal cerebral ischemia followed by reperfusion (MCAO/R). 6hrs post-MCAO, we administered tPA intravenously. Minocycline was administered intraperitoneally at various time points prior to tPA injection. One day post-stroke, we injected hNSCs intracranially. Previously, we reported that minocycline pretreatment prior to tPA and hNSC transplantation reduced the mortality of delayed tPA-treated aged mice within 48hrs post-stroke. In this study, we investigated the effect of hNSCs treated with minocycline-plus-delayed tPA treatment on long-term benefits on neurological function. We performed a behavioral test of motor function beginning 24hrs after hNSC transplantation. Rotarod test was carried out 3 days(d) consecutively pre-stroke (as training) and from 2d to 28d post-stroke. Here, we report that by combining minocycline prior to tPA significantly ameliorates neurological deficit in aged mice. Furthermore, transplanting hNSCs ameliorated the pathophysiology caused by delayed tPA.

Combination therapy for ischemic stroke: Novel approaches to lengthen therapeutic window of tissue plasminogen activator

Tissue plasminogen activator (tPA) thrombolysis continues to be the gold standard therapy for ischemic stroke. Due to the time-limited treatment window, within 4.5 h of stroke onset, and a variety of potentially deadly complications related to delayed administration, particularly hemorrhagic transformation (HT), clinical use of tPA is limited. Combination therapies with other interventions, drug or nondrug, have been hypothesized as a logical approach to enhancing tPA effectiveness. Here, we discuss various potential pharmacological and nondrug treatments to minimize adverse effects, primarily HT, associated with delayed tPA administration. Pharmacological interventions include many that support the integrity of the blood–brain barrier (i.e., atorvastatin, batimastat, candesartan, cilostazol, fasudil, and minocycline), promote vascularization and preserve cerebrovasculature (i.e., coumarin derivative IMM-H004 and granulocyte-colony stimulating factor), employing other mechanisms of action (i.e., oxygen transporters and ascorbic acid). Nondrug treatments are comprised of stem cell transplantation and gas therapies with multi-faceted approaches. Combination therapy with tPA and the aforementioned treatments demonstrated promise for mitigating the adverse complications associated with delayed tPA treatment and rescuing stroke-induced behavioral deficits. Therefore, the conjunctive therapy method is a novel therapeutic approach that can attempt to minimize the limitations of tPA treatment and possibly increase the therapeutic window for ischemic stroke treatment.

Adjunctive Therapy Approaches for Ischemic Stroke: Innovations to Expand Time Window of Treatment.

Tissue plasminogen activator (tPA) thrombolysis remains the gold standard treatment for ischemic stroke. A time-constrained therapeutic window, with the drug to be given within 4.5 h after stroke onset, and lethal side effects associated with delayed treatment, most notably hemorrhagic transformation (HT), limit the clinical use of tPA. Co-administering tPA with other agents, including drug or non-drug interventions, has been proposed as a practical strategy to address the limitations of tPA. Here, we discuss the pharmacological and non-drug approaches that were examined to mitigate the complications—especially HT—associated with delayed tPA treatment. The pharmacological treatments include those that preserve the blood-brain barrier (e.g., atovarstatin, batimastat, candesartan, cilostazol, fasudil, minocycline, etc.), enhance vascularization and protect the cerebrovasculature (e.g., coumarin derivate IMM-H004 and granulocyte-colony stimulating factor (G-CSF)), and exert their effects through other modes of action (e.g., oxygen transporters, ascorbic acid, etc.). The non-drug approaches include stem cell treatments and gas therapy with multi-pronged biological effects. Co-administering tPA with the abovementioned therapies showed promise in attenuating delayed tPA-induced side effects and stroke-induced neurological and behavioral deficits. Thus, adjunctive treatment approach is an innovative therapeutic modality that can address the limitations of tPA treatment and potentially expand the time window for ischemic stroke therapy.

NAD replenishment with nicotinamide mononucleotide protects blood-brain barrier integrity and attenuates delayed tissue plasminogen activator-induced haemorrhagic transformation after cerebral ischaemia.

Tissue plasminogen activator (tPA) is the only approved pharmacological therapy for acute brain ischaemia; however, a major limitation of tPA is the haemorrhagic transformation that follows tPA treatment. Here, we determined whether nicotinamide mononucleotide (NMN), a key intermediate of nicotinamide adenine dinucleotide biosynthesis, affects tPA-induced haemorrhagic transformation. Middle cerebral artery occlusion (MCAO) was achieved in CD1 mice by introducing a filament to the left MCA for 5h. When the filament was removed for reperfusion, tPA was infused via the tail vein. A single dose of NMN was injected i.p. (300mg·kg-1 ). Mice were killed at 24h post ischaemia, and their brains were evaluated for brain infarction, oedema, haemoglobin content, apoptosis, neuroinflammation, blood-brain barrier (BBB) permeability, the expression of tight junction proteins (TJPs) and the activity/expression of MMPs. In the mice infused with tPA at 5h post ischaemia, there were significant increases in mortality, brain infarction, brain oedema, brain haemoglobin level, neural apoptosis, Iba-1 staining (microglia activation) and myeloperoxidase staining (neutrophil infiltration). All these tPA-induced alterations were significantly prevented by NMN administration. Mechanistically, the delayed tPA treatment increased BBB permeability by down-regulating TJPs, including claudin-1, occludin and zonula occludens-1, and enhancing the activities and protein expression of MMP9 and MMP2. Similarly, NMN administration partly blocked these tPA-induced molecular changes. Our results demonstrate that NMN ameliorates tPA-induced haemorrhagic transformation in brain ischaemia by maintaining the integrity of the BBB.

Regulatory T cells ameliorate tissue plasminogen activator-induced brain haemorrhage after stroke.

Delayed thrombolytic treatment with recombinant tissue plasminogen activator (tPA) may exacerbate blood-brain barrier breakdown after ischaemic stroke and lead to lethal haemorrhagic transformation. The immune system is a dynamic modulator of stroke response, and excessive immune cell accumulation in the cerebral vasculature is associated with compromised integrity of the blood-brain barrier. We previously reported that regulatory T cells, which function to suppress excessive immune responses, ameliorated blood-brain barrier damage after cerebral ischaemia. This study assessed the impact of regulatory T cells in the context of tPA-induced brain haemorrhage and investigated the underlying mechanisms of action. The number of circulating regulatory T cells in stroke patients was dramatically reduced soon after stroke onset (84 acute ischaemic stroke patients with or without intravenous tPA treatment, compared to 115 age and gender-matched healthy controls). Although stroke patients without tPA treatment gradually repopulated the numbers of circulating regulatory T cells within the first 7 days after stroke, post-ischaemic tPA treatment led to sustained suppression of regulatory T cells in the blood. We then used the murine suture and embolic middle cerebral artery occlusion models of stroke to investigate the therapeutic potential of adoptive regulatory T cell transfer against tPA-induced haemorrhagic transformation. Delayed administration of tPA (10 mg/kg) resulted in haemorrhagic transformation in the ischaemic territory 1 day after ischaemia. When regulatory T cells (2 × 106/mouse) were intravenously administered immediately after delayed tPA treatment in ischaemic mice, haemorrhagic transformation was significantly decreased, and this was associated with improved sensorimotor functions. Blood-brain barrier disruption and tight junction damages were observed in the presence of delayed tPA after stroke, but were mitigated by regulatory T cell transfer. Mechanistic studies demonstrated that regulatory T cells completely abolished the tPA-induced elevation of MMP9 and CCL2 after stroke. Using MMP9 and CCL2 knockout mice, we discovered that both molecules partially contributed to the protective actions of regulatory T cells. In an in vitro endothelial cell-based model of the blood-brain barrier, we confirmed that regulatory T cells inhibited tPA-induced endothelial expression of CCL2 and preserved blood-brain barrier integrity after an ischaemic challenge. Lentivirus-mediated CCL2 knockdown in endothelial cells completely abolished the blood-brain barrier protective effect of regulatory T cells in vitro. Altogether, our studies suggest that regulatory T cell adoptive transfer may alleviate thrombolytic treatment-induced haemorrhage in stroke victims. Furthermore, regulatory T cell-afforded protection in the tPA-treated stroke model is mediated by two inhibitory mechanisms involving CCL2 and MMP9. Thus, regulatory T cell adoptive transfer may be useful as a cell-based therapy to improve the efficacy and safety of thrombolytic treatment for ischaemic stroke.

Neural Stem Cells Reduce Symptomatic Inflammation and Mortality in Aged Stroke Mice following Delayed tPA Treatment

Stem cell therapy offers great promise in treating stroke. Extensive injury from stroke results from ischemia‐reperfusion (IR), which damages the blood‐brain barrier (BBB), promotes inflammation and loss of cerebral parenchyma. Presently, tissue plasminogen activator (tPA) is the sole FDA‐approved antithrombotic treatment available for stroke. tPA has a narrow time window (<4.5hour) and delayed tPA (>5h) can exacerbate BBB damage and increase hemorrhagic complications. Our long‐term goal is to limit early‐stage BBB injuries, an outcome that would protect against the second phase of stroke damage. Aging is a strong risk factor for stroke but the harmful effects of delayed tPA (>4.5h), particularly on aged stroke animals, have not been well studied. We utilized a mouse model of stroke with middle cerebral artery occlusion (MCAO) to induce focal ischemia followed by reperfusion. We injected human neural stem cells (hNSCs) 24h after MCAO to correspond to the upregulation of endogenous proinflammatory cytokines. Previously, we reported that intracranial transplantation of hNSCs rapidly ameliorates BBB damage caused by ischemic stroke in young adult mice. In this study, we employed aged mice to test the effect of delayed tPA‐induced IR injury. We tested the hypothesis that hNSCs ameliorate pathophysiology of aged stroke mice after delayed tPA administration (6h post‐MCAO). We found that delayed tPA administration exacerbates BBB damage, upregulates inflammatory cytokines, and increases mortality. Engrafted hNSCs reduced BBB disruption, rapidly ameliorated symptomatic inflammation, and decreased mortality within 24h post‐transplantation (48h post‐MCAO). Our data demonstrate clear benefits of hNSCs during the early stage of ischemic stroke in aged stroke mice.Support or Funding Information1. Louisiana Clinical and Translational Science Center (LA CaTs), Pilot Grant, to J‐P. L. 2. Carol Lavin Bernick Faculty Grant to J‐P. L, Tulane University.

Abstract TP78: Combination of Neuroprotective Drug and Neural Stem Cells Benefits Aged Stroke Mice with Delayed Tissue Plasminogen Activator Treatment

Background: Presently, tissue plasminogen activator (tPA) is the sole FDA-approved antithrombotic treatment available for stroke. However, tPA’s harmful side effects within the central nervous system can exacerbate blood-brain barrier (BBB) damage and increase mortality. Patients should receive tPA less than 4.5 hours post-stroke. Although age alone is not an impediment for tPA treatment, the harmful effects of delayed tPA (>4.5h), particularly on aged stroke animals, have not been well studied. We reported that intracranial transplantation of neural stem cells (hNSCs) ameliorates BBB damage caused by ischemic stroke. In this study, we examined the combined effects of minocycline (a neuroprotective and anti-inflammatory drug) and hNSC transplantation on the mortality of delayed tPA-treated aged mice within 48h post-stroke. Methods and Results: We utilized the middle cerebral artery occlusion stroke mouse model to induce focal cerebral ischemia followed by reperfusion (MCAO/R). 6h post-MCAO, we administered tPA intravenously. Minocycline was administered intraperitoneally at various time points prior to tPA injection. One day post-stroke, we injected hNSCs intracranially. Previously, we reported that hNSCs (both human and mouse) transplanted into the brain 24h post-stroke rapidly improve neurological outcome in young-adult mice (4-5mo). In our current study, tPA administered within 4.5h did not increase mortality in either young-adult or aged mice. However, we found delayed tPA treatment (6h post-stroke) significantly increased the mortality of aged mice (13-18 mo) but not in young-adult mice. Here, we report that by combining minocycline prior to tPA significantly reduced mortality. Furthermore, transplanting hNSCs in minocycline-treated mice further ameliorated the pathophysiology caused by delayed tPA. Conclusions: Our findings implicate that administering the anti-apototic and anti-inflammatory drug prior to tPA injection, and then post-treating with multipotent neuroprotective hNSCs might expand the time window of tPA and reduce reperfusion injury.

Strategies to Extend Thrombolytic Time Window for Ischemic Stroke Treatment: An Unmet Clinical Need.

To date, reperfusion with tissue plasminogen activator (tPA) remains the gold standard treatment for ischemic stroke. However, when tPA is given beyond 4.5 hours of stroke onset, deleterious effects of the drug ensue, especially, hemorrhagic transformation (HT), which causes the most significant morbidity and mortality in stroke patients. An important clinical problem at hand is to develop strategies that will enhance the therapeutic time window for tPA therapy and reduce the adverse effects (especially HT) of delayed tPA treatment. We reviewed the pharmacological agents which reduced the risk of HT associated with delayed (beyond 4.5 hours post-stroke) tPA treatment in preclinical studies, which we classified into those that putatively preserve the blood-brain barrier (e.g., minocycline, cilostazol, fasudil, candesartan, and bryostatin) and/or enhance vascularization and protect the cerebrovasculature (e.g., coumarin derivate IMM-H004 and granulocyte colony-stimulating factor). Recently, other new therapeutic modalities (e.g., oxygen transporters) have been reported which improved delayed tPA-associated outcomes by acting through other mechanisms. While the above-mentioned interventions unequivocally reduced delayed tPA-induced HT in stroke models, the long-term efficacy of these drugs are not yet established. Further optimization is required to expedite their future clinical application. The findings from this review indicate the need to explore the most ideal adjunctive interventions that will not only reduce delayed tPA–induced HT, but also preserve neurovascular functions. While waiting for the next breakthrough drug in acute stroke treatment, it is equally important to allocate considerable effort to find approaches to address the limitations of the only FDA-approved stroke therapy.

Abstract WP97: Neuroprotective Effect of Progranulin Against Focal Cerebral Ischemia via Inhibition of Proteolysis of TDP-43 by Caspase-3

Introduction: We previously demonstrated that progranulin (PGRN), a glycoprotein growth factor, may be a novel therapeutic target that provides vascular protection and anti-neuroinflammation properties related in part to vascular endothelial growth factor and interleukin 10, respectively. We also found that PGRN could provide neuroprotection in part by inhibition of cytoplasmic redistribution of TAR DNA-binding protein-43 (TDP-43), although its exact mechanism remains poorly understood. The purpose of this study is to determine the mechanism of neuroprotection by PGRN against ischemic neuronal injury. Methods: The middle cerebral artery of adult PGRN knock-out (KO) mice (C57BL/6 background) and wild-type (WT) mice was occluded for 90 minutes. Immunohistochemical analysis using an antibody against TDP-43 was performed to investigate the subcellular localization of TDP-43 after ischemia. We also performed Western blot analysis to investigate the expression levels of TDP-43 and activated caspase-3 using cerebral cortex tissues from a rat autologous thromboembolic model with delayed tissue plasminogen activator (tPA) treatment (4 hours after ischemia). Results: Twenty-four hours after reperfusion, neuronal cells showing cytoplasmic redistribution of TDP-43 were more frequently observed in PGRN KO mice than in WT mice (P<0.01). In a rat autologous thromboembolic model with delayed tPA treatment, the expression level of full-length of TDP-43 decreased 24 hours after ischemia via proteolytic degradation. However, intravenous administration of recombinant PGRN with delayed tPA treatment inhibited the decrease in the expression level of full-length TDP-43 as well as the increase in the expression level of activated caspase-3 compared with that of the control protein. Conclusion: This study demonstrated that PGRN might protect neuronal cells against focal cerebral ischemia via inhibition of proteolysis and abnormal cytoplasmic redistribution of TDP-43 by caspase-3.

Delayed treatment with ADAMTS13 ameliorates cerebral ischemic injury without hemorrhagic complication

Tissue plasminogen activator (tPA) is the only approved therapy for acute ischemic stroke. However, delayed tPA treatment increases the risk of cerebral hemorrhage and can result in exacerbation of nerve injury. ADAMTS13, a von Willebrand factor (VWF) cleaving protease, has a protective effect against ischemic brain injury and may reduce bleeding risk by cleaving VWF. We examined whether ADAMTS13 has a longer therapeutic time window in ischemic stroke than tPA in mice subjected to middle cerebral artery occlusion (MCAO). ADAMTS13 (0.1mg/kg) or tPA (10mg/kg) was administered i.v., immediately after reperfusion of after 2-h or 4-h MCAO for comparison of the therapeutic time windows in ischemic stroke. Infarct volume, hemorrhagic volume, plasma high-mobility group box1 (HMGB1) levels and cerebral blood flow were measured 24h after MCAO. Both ADAMTS13 and tPA improved the infarct volume without hemorrhagic complications in 2-h MCAO mice. On the other hand, ADAMTS13 reduced the infarct volume and plasma HMGB1 levels, and improved cerebral blood flow without hemorrhagic complications in 4-h MCAO mice, but tPA was not effective and these animals showed massive intracerebral hemorrhage. These results indicated that ADAMTS13 has a longer therapeutic time window in ischemic stroke than tPA, and ADAMTS13 may be useful as a new therapeutic agent for ischemic stroke.

Normobaric hyperoxia slows blood-brain barrier damage and expands the therapeutic time window for tissue-type plasminogen activator treatment in cerebral ischemia.

Prolonged ischemia causes blood-brain barrier (BBB) damage and increases the incidence of neurovasculature complications secondary to reperfusion. Therefore, targeting ischemic BBB damage pathogenesis is critical to reducing neurovasculature complications and expanding the therapeutic time window of tissue-type plasminogen activator (tPA) thrombolysis. This study investigates whether increasing cerebral tissue PO2 through normobaric hyperoxia (NBO) treatment will slow the progression of BBB damage and, thus, improve the outcome of delayed tPA treatment after cerebral ischemia. Rats were exposed to NBO (100% O2) or normoxia (21% O2) during 3-, 5-, or, 7-hour middle cerebral artery occlusion. Fifteen minutes before reperfusion, tPA was continuously infused to rats for 30 minutes. Neurological score, mortality rate, and BBB permeability were determined. Matrix metalloproteinase-9 was measured by gelatin zymography and tight junction proteins (occludin and cluadin-5) by Western blot in the isolated cerebral microvessels. NBO slowed the progression of ischemic BBB damage pathogenesis, evidenced by reduced Evan blue leakage, smaller edema, and hemorrhagic volume in NBO-treated rats. NBO treatment reduced matrix metalloproteinase-9 induction and the loss of tight junction proteins in ischemic cerebral microvessels. NBO-afforded BBB protection was maintained during tPA reperfusion, resulting in improved neurological functions, significant reductions in brain edema, hemorrhagic volume, and mortality rate, even when tPA was given after prolonged ischemia (7 hours). Early NBO treatment slows ischemic BBB damage pathogenesis and significantly improves the outcome of delayed tPA treatment, providing new evidence supporting NBO as an effective adjunctive therapy to extend the time window of tPA thrombolysis for ischemic stroke.

Abstract W P238: Selective Deletion of Pi3-kinase Gamma in the Brain Inhibits Tissue Plasminogen Activator-induced Brain Hemorrhage

Background: PI3-kinase gamma (PI3Kγ), a key modulator in inflammation, is involved in many inflammatory diseases. We recently reported that PI3Kγ deficiency protects the brain from ischemic injury in PI3Kγ-/- mice by reducing blood-brain barrier damage and tissue infarction through inhibition of NF-kB-dependent inflammation, mainly involved in reduced MMP-9 activity in ischemic brain endothelium, microglia activation, and neutrophil infiltration into the ischemic brain. Meanwhile, we reported that ischemic brain endothelium, activated microglia, and infiltrating neutrophils represent the major cellular sources of PI3Kγ expressed in the brain within 24 h after cerebral ischemia. Brain hemorrhage is a serious complication of recombinant tissue plasminogen activator (tPA) therapy for ischemic stroke. In this study, we further investigated potential involvement of PI3Kγ, in particular the expression of PI3Kγ in the brain, in tPA-induced brain hemorrhage after ischemic stroke. Methods and Results: Focal ischemic stroke was induced by transient middle cerebral artery occlusion and reperfusion. PI3Kγ deficiency in PI3Kγ-/- mice not only reduced tissue infarction but also almost completely blocked brain hemorrhage induced by delayed tPA treatment at 6 hours after stroke. Bone marrow chimeras reveal that chimeric mice lacking PI3Kγ in the brain (WT BM →KO) blocked the delayed tPA-induced brain hemorrhage effectively as found in PI3Kγ-/- mice while chimeric mice lacking PI3Kγ expressed in leukocytes (KO BM →WT) had minimal effect on the tPA-induced brain hemorrhage. These effects could be attributed to a profound inhibition of MMP-9 activity in ischemic brain endothelium found in both PI3Kγ-/- mice and (WT BM →KO) chimeric mice but not in (KO BM →WT) chimeric mice, as determined by double IHC staining of MMP-9 in brain endothelial cells and by zymographic analysis of MMP-9 activity using microvessels isolated from the brain. Conclusion: Our findings suggest that PI3Kγ in the brain may play a predominant role in delayed tPA-induced brain hemorrhage after ischemic stroke. Our future study will define the role of PI3Kγ derived from brain endothelial cells versus microglia by generation of tissue/cell-specific knockout mice using the Cre-loxP system.