Thrombolysis and bridging therapy in patients with acute ischaemic stroke and Covid-19.

BACKGROUND AND PURPOSE: Comorbidity of acute ischaemic stroke with Covid-19 is a challenging condition, potentially influencing the decision of whether to administer intravenous thrombolysis (IVT). We aimed to assess the 1-month outcome in ischaemic stroke patients with Covid-19 infection who received IVT alone or before thrombectomy (bridging therapy). METHODS: As a collaboration initiative promoted by the Italian Stroke Organization, all Italian stroke units (n = 190) were contacted and invited to participate in data collection on stroke patients with Covid-19 who received IVT. RESULTS: Seventy-five invited centers agreed to participate. Thirty patients received IVT alone and 17 received bridging therapy between 21 February 2020 and 30 April 2020 in 20 centers (n = 18, Northern Italy; n = 2, Central Italy). At 1 month, 14 (30.4%) patients died and 20 (62.5%) survivors had a modified Rankin Scale (mRS) score of 3 to 5. At 24 to 36 hours, asymptomatic intracerebral hemorrhage (ICH) was reported in eight (17.4%) patients and symptomatic ICH (sICH) in two (4.3%) patients. Causes of death were severe ischaemic stroke (n = 8), a new ischaemic stroke (n = 2), acute respiratory failure (n = 1), acute renal failure (n = 1), acute myocardial infarction (n = 1), and endocarditis (n = 1). In survivors with a 1-month mRS score of 3 to 5, baseline glucose level was higher, whereas endovascular procedure time in cases of bridging therapy was longer. Baseline National Institutes of Health Stroke Scale glucose and creatinine levels were higher in patients who died. CONCLUSIONS: Intravenous thrombolysis for patients with stroke and Covid-19 was not a rare event in the most affected areas by pandemic, and rates of 1-month unfavorable outcomes were high compared to previous data from the pre-Covid-19 literature. However, risk of sICH was not increased.

Creatine salts provide neuroprotection even after partial impairment of the creatine transporter.

Creatine, a compound that is critical for energy metabolism of nervous cells, crosses the blood-brain barrier (BBB) and the neuronal plasma membrane with difficulty, and only using its specific transporter. In the hereditary condition where the creatine transporter is defective (creatine transporter deficiency) there is no creatine in the brain, and administration of creatine is useless lacking the transporter. The disease is severe and incurable. Creatine-derived molecules that could cross BBB and plasma membrane independently of the transporter might be useful to cure this condition. Moreover, such molecules could be useful also in stroke and other brain ischemic conditions. In this paper, we investigated three creatine salts, creatine ascorbate, creatine gluconate and creatine glucose. Of these, creatine glucose was ineffective after transporter block with guanidine acetic acid (GPA) administration. Creatine ascorbate was not superior to creatine in increasing tissue creatine and phosphocreatine content after transporter impairment, however even after such impairment it delayed synaptic failure during anoxia. Finally, creatine gluconate was superior to creatine in increasing tissue content of creatine after transporter block and slowed down PS disappearance during anoxia, an effect that creatine did not have. These findings suggest that coupling creatine to molecules having a specific transporter may be a useful strategy in creatine transporter deficiency. In particular, creatine ascorbate has effects comparable to those of creatine in normal conditions, while being superior to it under conditions of missing or impaired creatine transporter.

Validation of a simple method for atrial fibrillation screening in patients with stroke.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adult and old people and represents a risk factor for stroke. Correct AF individuation bears strong relevance in primary and secondary stroke prevention. Our goal was to evaluate the reliability of a low-cost, non-invasive technology in detecting AF in acute stroke patients. AFib model BP3MQ1-2D (Microlife USA, Dunedin, FL) showed good accuracy in diagnosing AF in a general cardiologic outpatient population. We carried out an observational study in patients with recent stroke. We studied 207 subjects, 103 men, 104 women, mean age (±SD) 77.7 ± 11.34 years, who underwent a test by AFib device with indication of AF or lack of it. The golden standard was a 12-lead EKG done immediately and evaluated by a certified cardiologist. We computed estimates of Sensitivity and Specificity and their 95 % confidence intervals (CI). AF was present in 38 subjects from the sample of 207 (18.4 %). AFib correctly demonstrated AF in 34 and failed diagnosing AF in 4 cases; on the other hand, AFib correctly excluded AF in 167 and caused an erroneous diagnosis of AF in 2 cases. The Sensitivity was 0.895 (95 % CI 0.7597-0.958) and the Specificity was 0.988 (95 % CI 0.958-0.997). The AFib device global accuracy was 0.971 (95 % CI 0.938-0.987). This device was able to detect AF with high specificity and a good sensitivity. This device may be considered as an accurate tool in detecting AF in stroke patients.

Influence of vascular risk factors and neuropsychological profile on functional performances in CADASIL: results from the MIcrovascular LEukoencephalopathy Study (MILES).

BACKGROUND AND PURPOSE: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited cerebral small vessel disease that may lead to disability and whose phenotype modulators are still unknown. METHODS: In the MIcrovascular LEukoencephalopathy Study (MILES), we assessed the influence of vascular risk factors and the effect of different cognitive domains (memory, psychomotor speed and executive functions) performances on functional abilities in CADASIL in comparison with age-related leukoencephalopathy (ARL). RESULTS: We evaluated 51 CADASIL patients (mean age 50.3 ± 13.8 years, 47.1% males) and 68 ARL patients (70.6 ± 7.4 years, 58.8% males). Considering vascular risk factors, after adjustment for age, CADASIL patients had higher mean BMI values than ARL patients. Stroke history frequency was similar in the two groups. After adjustment for age, more CADASIL patients were disabled (impaired on ≥ 2 items of the Instrumental Activities of Daily Living scale) in comparison with ARL patients, and CADASIL patients had worse functional performances evaluated with the Disability Assessment for Dementia (DAD) scale. In CADASIL patients, hypertension was related to both DAD score and disability. The cognitive profile of CADASIL and ARL patients was similar, but on a stepwise linear regression analysis functional performances were mainly associated with the memory index (ß = -0.418, P < 0.003) in CADASIL patients and the executive function index (ß = -0.321, P = 0.028) in ARL. CONCLUSIONS: This study suggests that hypertension may contribute to functional impairment in CADASIL and that memory impairment has a large influence on functional decline in contrast with that observed in a sample of subjects with ARL.

Creatine ethyl ester: a new substrate for creatine kinase.

The creatine kinase/phosphocreatine system plays a key role in cell energy buffering and transport, particularly in cells with high or fluctuating energy requirements, like neurons, i.e. it participates in the energetic metabolism of the brain. Creatine depletion causes several nervous system diseases, alleviated by phosphagen supplementation. Often, the supplementation contains both creatine and creatine ethyl ester, known to improve the effect of creatine through an unknown mechanism. In this work we showed that purified creatine kinase is able to phosphorilate the creatine ethyl ester. The K(m) and V(max) values, as well as temperature and pH optima were determined. Conversion of the creatine ethyl ester into its phosphorylated derivative, sheds light on the role of the creatine ethyl ester as an energy source in supplementation for selected individuals.

Searching for a therapy of creatine transporter deficiency: some effects of creatine ethyl ester in brain slices in vitro.

Creatine, an ergogenic compound essential for brain function, is very hydrophilic and needs a transporter to cross lipid-rich cells' plasma membranes. Hereditary creatine transporter deficiency is a severe incurable neurological disease where creatine is missing from the brain. Creatine esters are more lipophylic than creatine and may not need the transporter to cross plasma membranes. Thus, they may represent a useful therapy for hereditary creatine transporter deficiency. Creatine ethyl ester (CEE) is commercially available and widely used as a nutritional supplement. It was reported that it enters the cells of patients lacking the transporter but was not useful when administered in vivo, by oral route, to affected patients. In this paper we investigated the effects of CEE in in vitro brain slices before and after biochemical block of the creatine transporter. We found that CEE is rapidly degraded in the aqueous incubation medium to creatinine, however it remains in solution long enough to cause an increase in tissue content of creatine and, more prominently, phosphocreatine. Both CEE and creatine delayed the anoxia-induced failure of synaptic transmission, and there was no difference between the two compounds. Contrary to what we expected, CEE did not increase tissue creatine content after the creatine transporter was blocked. We confirm that CEE is probably not an effective treatment for hereditary creatine transporter deficiency. Two factors seem to affect the possibility for creatine esters to be exploited in the therapy of creatine transporter deficiency. First, the size of their alcohol moiety should be increased since this would increase the lipophilicity of the compound and improve its ability to diffuse through biological membranes. Second, creatine esters should be further modified to slow their degradation to creatinine and increase their half-life in aqueous solutions. Moreover, we should not forget the possibility that they are degraded in vivo by plasma esterases.

In vivo neuroprotection by a creatine-derived compound: phosphocreatine-Mg-complex acetate.

Phosphocreatine-Mg-complex acetate (PCr-Mg-CPLX) is a creatine-derived compound that in previous in vitro research was able to increase neuronal creatine independently of the creatine transporter, thus providing hope to cure the hereditary syndrome of creatine transporter deficiency. In previous research we showed that it reproduces in vitro the known neuroprotective effect of creatine against anoxic damage. In the present paper we investigated if PCr-Mg-CPLX reproduces this neuroprotective effect in vivo, too. We used a mouse model of transient middle cerebral artery occlusion. Mice received PCr-Mg-CPLX or a mixture of the two separate compounds phosphocreatine (PCr) and MgSO(4), or vehicle. The injections were done 60 min and 30 min before ischemia. Forty-eight hours after ischemia neurological damage was evaluated with Clark's behavioural tests, then the infarct volume was measured. PCr-Mg-CPLX reduced the infarct volume by 48%, an effect that was not duplicated by the separate administration of PCr and MgSO(4) and the neurological damage was decreased in a statistically significant way. We conclude that PCr-Mg-CPLX affords in vivo neuroprotection when administered before ischemia. These results are comparable to previous research on creatine administration in experimental stroke. PCr-Mg-CPLX maintains creatine-like neuroprotective effects in vivo as well as in vitro. Our study suggests that PCr-Mg-CPLX might have a therapeutic role in the treatment of hereditary creatine transporter deficiency and of conditions where there is a high risk of impending stroke or cerebral ischemic damage, like high-risk transient ischemic attacks, open heart surgery, and carotid surgery.

Stroke due to atrial fibrillation and the attitude to prescribing anticoagulant prevention in Italy. A prospective study of a consecutive stroke population admitted to a comprehensive stroke unit.

BACKGROUND: Several studies have reported that oral anticoagulant prophylaxis (OAC) is under-used in patients with atrial fibrillation (AF). OBJECTIVE: This study investigated the attitude to prescribing OAC in patients with AF observed in an Italian Stroke Unit (SU) and the severity of ischemic stroke due to AF in comparison with that of other etiologies. METHODS: We prospectively studied a continuous series of acute stroke patients admitted to our SU from January 1, 2003 to December 31, 2005. Using Multiple Logistic Regression, we analyzed factors associated with the non-use of OAC and with poor prognosis. RESULTS: Of 400 consecutive ischemic stroke patients, 103 (25.75 %) had AF; this group was older (mean age+/-sd= 79.74 +/- 10.15 years vs. 73.49 +/- 12.72; P = 0.0000045) and their strokes were more severe (NIHSS median value = 10 vs. 7, P < 0.002) in comparison with the group of patients whose strokes were due to other etiologies. Only 27.27% of patients with known AF, and without contraindications, were under OAC before the onset of stroke. The main independent factor associated with the non-use of OAC was old age. Moreover, AF proved to be a significant independent predictor of poor prognosis in our stroke population. CONCLUSIONS: The results of this study indicate a marked under- use of OAC prophylaxis in AF subjects in Italy. Campaigns to raise awareness and to improve the implementation of guidelines on stroke prevention strategies are strongly recommended, not least because stroke due to AF has a worse prognosis.

Activation of cerebellar granule cells GABA(A) receptors by guanidinoacetate.

The extracellular concentration of guanidinoacetate (GAA) in the brain increases in guanidino acetate methyl transferase (GAMT) deficiency, an inherited disorder. We tested whether the levels which this substance can reach in the brain in GAMT deficiency are able to activate GABA(A) receptors in key cerebellar neurons such as the cerebellar granules. GAA in fact activates these receptors in rat cerebellar granules in culture although at quite high concentrations, in the millimolar range. However, these millimolar GAA levels are not reached extracellularly in the brain in GAMT deficiency. In addition, GAA does not act as a partial agonist on granules' GABA(A) receptors. This appears to deny an effect by this molecule on cerebellar function in the disease via interference with granule cells' GABA(A) receptors. Study of partial blockage by furosemide of chloride currents activated by GABA and GAA in granule cells allowed us to distinguish two populations of GABA(A) receptors presumably involved in granule cells' tonic inhibition. One is devoid of alpha6 subunit and another one contains it. The latter when activated by GABA has a decay kinetics much slower than the former. GAA does not distinguish between these two populations. In any case, the very high extracellular GAA concentrations able to activate them are not likely to be reached in GAMT deficiency.

Sex differences in human lymphocyte Na,K-ATPase as studied by labeled ouabain binding.

Lymphocytes Na,K-ATPase is a plasma membrane enzyme that is up-regulated under lymphocytes activation. It is also studied as a model of brain cells Na,K-ATPase. Data about sex-related specificities of the enzyme are not available. The binding of tritium-labelled ouabain to lymphocyte plasma membrane Na,K-ATPase was studied in healthy volunteers of both sexes. The binding interactions were expressed in terms of K(D) and B(Max). The first parameter is related to the affinity of ouabain for the enzyme whereas the second one is related to its density on the cell membrane. Distinct sex-related differences were found. Whereas in males there is a significant direct correlation between the parameters K(D) and B(Max), in females this is not present. However, in females there is a significantly lower K(D) in the 25-37 age range. The latter result probably reflects the expression of subunit variants giving a greater affinity for ouabain. This circumstance may be relevant both to lymphocytes' ability to be activated and to brain function, if one admits that lymphocyte Na,K-ATPase faithfully represents the brain-borne one.

Abnormalities of Na/K ATPase in migraine with aura.

It has been previously shown from our laboratory that abnormal functioning of Na/K ATPase can cause spreading depression, the likely mechanism of migraine aura. We used lymphocytes to investigate whether or not membrane Na/K ATPase is altered in migraine with aura patients. Lymphocytes were prepared from such patients, aged 20-45 years, and from age-matched healthy volunteers (controls). The binding of 3H- ouabain was studied using increasing concentrations (0.5-25 nm) of this radioligand, specific for Na/K-ATPase. We studied 19 migraine with aura patients and 22 healthy volunteers, matched for age and sex. B(max) (fmol/mg protein) and K(D) (nM) were not different between patients and controls. However, their ratio (B(max)/K(D)) was higher in patients than in controls. B(max) was (mean +/- SD) 270 +/- 110 fmol/mg protein in controls, and 360 +/- 230 in migraine with aura patients (P = 0.10, t-test). K(D) was (mean +/- SD) 2.8 +/- 1.5 nm in controls, and 2.9 +/- 3.2 nm in migraine with aura patients (P = 0.88, t-test). B(max)/K(D) was (mean +/- SD) 120 +/- 78 in controls, and 210 +/- 190 in migraine patients (P = 0.046, t-test). Moreover, no control patient had a B(max)/K(D) ratio greater than 398, while three migraine patients had ratios of 417, 572 and 722, respectively. Ouabain binding is affected by Na/K ATPase structure (K(D)) and expression (B(max)). While these parameters were not altered in migraine with aura patients, the difference in their ratio suggests an imbalance between the enzyme's ouabain affinity and its expression, with higher-affinity subtypes being more expressed than normal. Moreover, single patients had values quite different from the control population. Our data suggest that (i) ouabain binding to lymphocyte membranes may be a useful tool in the diagnosis of migraine with aura and (ii) Na/K ATPase abnormalities may be involved in migraine aura.

The creatine transporter mediates the uptake of creatine by brain tissue, but not the uptake of two creatine-derived compounds.

Hereditary creatine transporter deficiency causes brain damage, despite the brain having the enzymes to synthesize creatine. Such damage occurring despite an endogenous synthesis is not easily explained. This condition is incurable, because creatine may not be delivered to the brain without its transporter. Creatine-derived compounds that crossed the blood-brain barrier in a transporter-independent fashion would be useful in the therapy of hereditary creatine transporter deficiency, and possibly also in neuroprotection against brain anoxia or ischemia. We tested the double hypothesis that: (1) the creatine carrier is needed to make creatine cross the plasma membrane of brain cells and (2) creatine-derived molecules may cross this plasma membrane independently of the creatine carrier. In in vitro mouse hippocampal slices, incubation with creatine increased creatine and phosphocreatine content of the tissue. Inhibition of the creatine transporter with 3-guanidinopropionic acid (GPA) dose-dependently prevented this increase. Incubation with creatine benzyl ester (CrOBzl) or phosphocreatine-Mg-complex acetate (PCr-Mg-CPLX) increased tissue creatine content, not phosphocreatine. This increase was not prevented by GPA. Thus, the creatine transporter is required for creatine uptake through the plasma membrane. Since there is a strong indication that creatine in the brain is mainly synthesized by glial cells and transferred to neurons, this might explain why hereditary transporter deficiency is attended by severe brain damage despite the possibility of an endogenous synthesis. CrOBzl and PCr-Mg-CPLX cross the plasma membrane in a transporter-independent way, and might be useful in the therapy of hereditary creatine transporter deficiency. They may also prove useful in the therapy of brain anoxia or ischemia.

Intracerebroventricular administration of creatine protects against damage by global cerebral ischemia in rat.

Although a large body of evidence shows that pretreatment of brain tissue with creatine protects against anoxic injury in vitro, only a couple of papers have investigated creatine protection in vivo, and they yielded conflicting results. We attempted to clarify how creatine may be protective in an in vivo model of global cerebral ischemia (GCI). We administered creatine either before of after GCI. We decided to administer it by intracerebroventricular infusion, to maximize its bioavailability to the brain. Our findings show that creatine is clearly protective in vivo when administered before ischemia. In that case, histological evaluation of damage was consistently improved in all regions examined, and neurological score was better in creatine-treated rats than in controls. When administered after ischemia, histology was improved in the hippocampus, while only a not significant trend toward improvement was observed in the cerebral cortex and in the caudo-putamen. Neurological score was not improved by creatine administration after GCI. Our findings show that creatine administration is protective in vivo. Such protection was clear in the case of pretreatment, and was present, to a lesser degree, when treatment was started after ischemia. Our results should encourage further research in the possible role of creatine therapy in neuroprotection.

Structural organization of astrocytes in the rat hippocampus in the post-ischemic period.

The aim of the present work was to study the location and structural organization of astrocytes in the rat hippocampus, which contain immunoreactive glial fibrillary acid protein (GFAP) after ischemic damage to the brain after intracerebroventricular administration of the neuroprotective agent creatine and without treatment. Light microscopy and immunocytochemical methods were used to study the brains of 26 adult male Sprague-Dawley (Koltushi) rats, some of which were subjected to total cerebral ischemia (12 min) under anesthesia with subsequent reperfusion (seven days). Creatine was given to 11 animals intracerebroventricularly using an osmotic pump (Alzet Osmotic Mini-Pump). The results showed that GFAP-immunoreactive hippocampal astrocytes were concentrated in two main zones (the stratum lacunosum-moleculare of field CA1 and the stratum polymorphae of the dentate fascia). The neuroprotective effect of creatine had the result that moderate ischemic damage to the hippocampus did not lead to changes in the zones containing activated astrocytes. The redistribution of GFAP-positive astrocytes in the post-ischemic period was associated with loss of pyramidal neurons in cytoarchitectonic field CA1. Complete loss of pyramidal neurons in this area of the hippocampus leads to a qualitatively new level of astrocyte activation--proliferation.

[Structural characteristics of astrocytes from the rat hippocampus in postischemia]. / Strukturnaia organizatsiia astrotsitov gippokampa krysy v postishemicheskii period.

The aim of this investigation was to study the distribution and structural organization of rat hippocampal astrocytes containing immunoreactive glial fibrillary acidic protein (GFAP) after ischemic damage of the brain in the animals treated with intraventricular infusion of creatine as a neuroprotective drug, and in those which received no treatment. Using the methods of light microscopy and immunocytochemistry, the brain of 26 mature Sprague-Dawley (Koltushi) rats was studied. Some animals were narcotized and subjected to general brain ischemia (lasting for 12 min) followed by a reperfusion (for 7 days). Creatine was infused intraventricularly to 11 animals using an automatic Alzet osmotic minipump. It was found that GFAP-immunoreactive hippocampal astrocytes were concentrated within two major areas (stratum lacunosum-moleculare CA1 and fascia dentata stratum polymorphae). As a result of neuroprotective effect of creatine, moderate ischemic damage of the hippocampus was not followed by the changes in the zones of activated astrocyte localization. Redistribution of GFAP-positive astrocytes in postischemic period was caused by the loss of pyramidal neurons in cytoarchitectonic field CA1. Complete loss of pyramidal neurons in this hippocampal area resulted in a qualitatively new level of astrocyte activation--their proliferation.

Role of creatine and phosphocreatine in neuronal protection from anoxic and ischemic damage.

Phosphocreatine can to some extent compensate for the lack of ATP synthesis that is caused in the brain by deprivation of oxygen or glucose. Treatment of in vitro rat hippocampal slices with creatine increases the neuronal store of phosphocreatine. In this way it increases the resistance of the tissue to anoxic or ischemic damage. In in vitro brain slices pretreatment with creatine delays anoxic depolarization (AD) and prevents the irreversible loss of evoked potentials that is caused by transient anoxia, although it seems so far not to be active against milder, not AD-mediated, damage. Although creatine crosses poorly the blood-brain barrier, its administration in vivo at high doses through the intracerebroventricular or the intraperitoneal way causes an increase of cerebral phosphocreatine that has been shown to be of therapeutic value in vitro. Accordingly, preliminary data show that creatine pretreatment decreases ischemic damage in vivo.

Electrophysiological effects of sustained delivery of CRF and its receptor agonists in hippocampal slices.

The corticotropin-releasing factor (CRF) is a hypothalamic peptide that regulates the release of adrenocorticotropic hormone (ATCH) and of beta-endorphin. It has been suggested that it modulates learning and memory processes in rat. However, the electrophysiological effects that CRF produces on hippocampal neurons have been so far little investigated. In particular, the effects of CRF on long-term potentiation (LTP), a phenomenon which is thought to be the substrate of memory processes, are unknown. We studied the effects of sustained administration of CRF and of two of its receptor agonists on basal neuronal activity and on in vitro hippocampal LTP. The two receptor agonists were D-Glu-20-CRF and D-Pro-5-CRF, selective for the CRF-R1 and the CRF-R2 receptors, respectively. We found that CRF, D-Pro-5-CRF and D-Glu-20-CRF at the concentration of 1 nM diminish the amplitude of hippocampal population spike and prevent the onset of LTP. Higher concentrations of CFR have less depressing effects on neuronal activity, yet they still prevent the occurrence of LTP.