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To analyse the influence of socioeconomic status on the clinical profile of patients undergoing non-traumatic lower-limb amputation.Retrospective study of 697 lower-limb amputee patients in an Angiology and Vascular Surgery Department during a 5-year period. Patients were classified according to their socioeconomic status (low, medium and high). We analysed demographic (age and gender) and clinical variables (cause of amputation, comorbidity, cardiovascular risk factors and amputation level).Mean age was 70.5 ± 11.9 years, and the median was 72 years. The low socioeconomic status group presented a higher frequency of amputations in men. Cardiovascular risks factors were more frequent in this socioeconomic group, and the difference was statistically significant for diabetes (85.8% low, 69.3% medium, 65% high; P.01) and obesity (31.4% low, 22.6% medium, 12.5% high, P.01). Diabetic retinopathy was the only comorbidity with a significant association with low socioeconomic status (21.1% low, 15.3% medium, 12.5% high, P.03). Regarding the cause for amputation, there was no difference in terms of socioeconomic status. The low socioeconomic level showed a higher frequency of major amputation, which was a significant difference (63.6% low, 41.2% medium, 55% high, P.04) and a higher predisposition for this amputation level.The low socioeconomic status has been shown to determine an unfavourable vascular risk profile in lower-limb non-traumatic amputees and a higher predisposition of a major amputation. This socioeconomic level demonstrates a negative influence on these patients' diabetes, obesity and diabetic retinopathy.

Resumen Introduccion Analizar la influencia del nivel socioeconomico (NSE) sobre el perfil clinico del paciente amputado de miembro inferior por causa no traumatica. Metodos Estudio retrospectivo con 697 pacientes amputados de miembro inferior, en un Servicio de Angiologia y Cirugia Vascular, durante un periodo de 5 anos. Los pacientes fueron divididos segun NSE (bajo, medio y alto). Se analizaron variables demograficas (edad y genero) y clinicas (causa, comorbilidad, factores de riesgo cardiovascular y nivel de amputacion) Resultados La edad media fue 70,5 ± DE 11,9 anos y la mediana 72 anos. El NSE bajo presento mayor frecuencia de hombres amputados. Todos los factores de riesgo cardiovascular fueron mas frecuentes en este nivel, aunque solo fue estadisticamente significativo en diabetes (85,8% bajo, 69,3% medio, 65% alto; p Conclusiones El NSE bajo determina un perfil de riesgo vascular mas desfavorable en los pacientes amputados de miembro inferior por causa no traumatico y una mayor predisposicion a sufrir amputacion mayor. Este NSE muestra una influencia negativa sobre diabetes, obesidad y retinopatia diabetica en estos pacientes.

Extracellular vesicles (EVs) are involved in intercellular signalling through the transfer of molecules during physiological and pathological conditions, such as ischaemic disease. EVs might therefore play a role in ischaemic stroke (IS) and myocardial infarction (MI). In the present study, we analysed the similarities and differences in the content of circulating EVs in patients with IS and MI. This prospective observational study enrolled 140 participants (81 patients with IS, 37 with MI and 22 healthy controls [HCs]). We analysed the protein and microRNA content from EVs using proteomics and reverse transcription quantitative real-time polymerase chain reaction and compared it between the groups. In the patients with IS and MI, we identified 14 common proteins. When comparing IS and MI, we found differences in the protein profiles (apolipoprotein B, alpha-2-macroglobulin, fibronectin). We also found lower levels of miR-340 and miR-424 and higher levels of miR-29b in the patients with IS and MI compared with the HCs. Lastly, we found higher miR-340 levels in IS than in MI. In conclusion, proteomic and miRNA analyses suggest a relationship between circulating EV content and the patient’s disease state. Although IS and MI affect different organs (brain and heart) with distinct histological characteristics, certain EV proteins and miRNAs appear to participate in both diseases, while others are present only in patients with IS., This work was sponsored by a grant from Miguel Servet (CP15/00069 to María Gutiérrez- Fernández), a predoctoral fellowship (FI17/00188 to Mari Carmen Gómez-de Frutos;FI18/00026 to Fernando Laso-García), a Sara Borrell postdoctoral fellowship (CD19/00033 to María Pérez-Mato), the INVICTUS PLUS network grant (RD16/0019/0005) from the Carlos III Health Institute Health Care Research Fund and was co-funded by the European Regional Development Fund (ERDF) and Juan de la Cierva postdoctoral fellowship (IJCI-2017-33505 to Laura Otero-Ortega, Spanish State Research Agency) and the Spanish Ministry of Science and Innovation.

Los autores agradecen al Servicio de Angiología y Cirugía Vascular del Hospital Universitario San Cecilio de Granada, España., Objetivo: Analizar las diferencias según el sexo en el perfil clínico de riesgo de los pacientes amputados de miembro inferior por causa no traumática. Método: Estudio retrospectivo descriptivo con 697 pacientes amputados de miembro inferior por causa no traumática, en un Servicio de Angiología y Cirugía Vascular, durante un periodo de 5 años y divididos en función del sexo. Se analizaron variables demográficas (edad) y clínicas (causa, comorbilidad, factores de riesgo cardiovascular y nivel de amputación). Resultados: La edad media (± desviación estándar) de las mujeres fue mayor (75.3 ± 12 frente a 68.9 ± 11 años; p < 0.001) y ellas presentaron mayor frecuencia de factores de riesgo cardiovascular concomitantes, tales como diabetes, hipertensión y obesidad, que los varones, mientras que ellos presentaron mayor frecuencia de tabaquismo. No hubo diferencia significativa entre sexos respecto a la distribución de las causas de amputación, siendo la principal causa la isquémica, destacando la arteriosclerosis. Las mujeres presentaron mayor frecuencia y predisposición para un nivel de amputación mayor. Conclusiones: En nuestro estudio, las mujeres presentaron un perfil de riesgo cardiovascular más desfavorable y el sexo femenino fue un predictor independiente de amputación mayor de miembro inferior por causa no traumática., Objectives: To analyse the possible gender differences within the clinical risk profile of lower-limb amputee patients who had a non-traumatic amputation. Method: A retrospective study with 697 lower-limb amputee patients, classified according to their gender, has been conducted at the Angiology and Vascular Surgery Department for 5 years. The variables considered were demographic variables (age and gender) and clinic variables (cause of the amputation, comorbidity, cardiovascular risk factors and the amputation level). Results: Regarding to the results, the average of women was older than men (75.3 ± 12 vs. 68.9 ± 11 years; p < 0.001), showing an increasing frequency to concomitant cardiovascular risk factors, such as diabetes, hypertension, and obesity. However, men present a higher frequency to smoking. There were no gender differences in the main cause of the amputation, the ischemic cause, being notably into this cause the subgroup of arteriosclerosis cause. Women showed a higher frequency and predisposition for major amputation. Conclusions: This study showed that women had a more unfavorable cardiovascular risk profile than men, being the female gender an independent predictor to a major lower-limb amputation with non-traumatic amputation.

[Introduction] Stroke is a serious public health problem, given it is a major cause of disability worldwide despite the spread of recanalisation therapies. Enhancement of brain plasticity with stem cell administration is a promising innovative therapy to reduce sequelae in these patients., [Methods and analysis] We have developed a phase IIb, multicentre, randomised, double-blind, placebo-controlled clinical trial protocol to evaluate the safety and efficacy of intravenous administration of allogeneic adipose tissue-derived mesenchymal stem cells (AD-MSCs) in patients with acute ischaemic stroke, concurrently with conventional stroke treatment. Thirty patients will be randomised on a 1:1 basis to receive either intravenous placebo or allogeneic AD-MSCs as soon as possible within the first 4 days from stroke symptom onset. Patients will be followed up to 24 months after randomisation. The primary objective is the safety assessment of early intravenous administration of allogeneic AD-MSCs by reporting all adverse events and neurological or systemic complications in both treatment groups. Secondary objectives assess efficacy of early intravenous AD-MSC treatment in acute ischaemic stroke by evaluating changes in the modified Rankin Scale and the National Institutes of Health Stroke Scale throughout the follow-up period. In addition, brain repair biomarkers will be measured at various visits., [Ethics and dissemination] This clinical trial has been approved by the Clinical Research Ethics Committee of La Paz University Hospital (Madrid, Spain) and by the Spanish Agency of Medication and Health Products and has been registered in Eudra CT (2019-001724-35) and ClinicalTrials.gov (NCT04280003). Study results will be disseminated through peer-reviewed publications in Open Access format and at conference presentations., This clinical trial has been promoted by the La Paz University Hospital Institute for Health Research—IdiPAZ (La Paz University Hospital—Universidad Autónoma de Madrid) and sponsored from a competitive grant from the Carlos III Health Institute Healthcare Research Fund, and cofunded by the European Regional Development Fund (ERDF) 'A way to make Europe'/'Investing in your future' (PIC18/00016). This clinical trial has been supported by Plataforma Española de Investigación Clínica y Ensayos Clínicos, SCReN (Spanish Clinical Research Network), funded by Carlos III Health Institute-General Subdirection for Evaluation and Promotion of Research, research PT17/0017/0013; State Plan for Scientific Investigation, Technology and Innovation (2017–2020) and cofunded by European Regional Development Fund/European Social fund 'A way to make Europe'/'Investing in your future' (grant ID PT17/0017/0013).

In order to investigate the role of circulating extracellular vesicles (EVs), proteins, and microRNAs as damage and repair markers in ischaemic stroke depending on its topography, subcor-tical (SC), and cortical-subcortical (CSC) involvement, we quantified the total amount of EVs using an enzyme-linked immunosorbent assay technique and analysed their global protein content using proteomics. We also employed a polymerase chain reaction to evaluate the circulating microRNA profile. The study included 81 patients with ischaemic stroke (26 SC and 55 CSC) and 22 healthy controls (HCs). No differences were found in circulating EV levels between the SC, CSC, and HC groups. We detected the specific expression of C1QA and Casp14 in the EVs of patients with CSC ischaemic stroke and the specific expression of ANXA2 in the EVs of patients with SC involvement. Patients with CSC ischaemic stroke showed a lower expression of miR-15a, miR-424, miR-100, and miR-339 compared with those with SC ischaemic stroke, and the levels of miR-339, miR-100, miR-199a, miR-369a, miR-424, and miR-15a were lower than those of the HCs. Circulating EV proteins and microRNAs from patients with CSC ischaemic stroke could be considered markers of neurite outgrowth, neurogenesis, inflammation process, and atherosclerosis. On the other hand, EV proteins and microRNAs from patients with SC ischaemic stroke might be markers of an anti-inflammatory process and blood–brain barrier disruption reduction., This work was sponsored by a grant from Miguel Servet (CP15/00069; CPII20/00002 to María Gutiérrez-Fernández), Miguel Servet (CP20/00024 to Laura Otero-Ortega), a predoctoral fellowship (FI17/00188 to Mari Carmen Gómez-de Frutos; FI18/00026 to Fernando Laso-García), a Sara Borrell postdoctoral fellowship (CD19/00033 to María Pérez-Mato), a Río Hortega (CM20/00047 to Elisa Alonso-López) and the INVICTUS PLUS network grant (RD16/0019/0005) from the Carlos III Health Institute Health Care Research Fund and was co-funded by the European Regional Development Fund (ERDF).

Background and purpose The aim was to identify whether post-stroke hyperglycaemia (PSH) influences the levels of circulating biomarkers of brain damage and repair, and to explore whether these biomarkers mediate the effect of PSH on the ischaemic stroke (IS) outcome. Methods This was a secondary analysis of the Glycaemia in Acute Stroke II study. Biomarkers of inflammation, prothrombotic activity, endothelial dysfunction, blood-brain barrier rupture, cell death and brain repair processes were analysed at 24-48 h (baseline) and 72-96 h (follow-up) after IS. The associations of the biomarkers and stroke outcome (modified Rankin Scale score at 3 months) based on the presence of PSH were compared. Results A total of 174 patients participated in this sub-study. Brain-derived neurotrophic factor (BDNF) at admission was negatively correlated with glucose levels. PSH was associated with a trend toward higher levels of endothelial progenitor cells (EPCs) at baseline. The EPCs in the PSH group then decreased in the follow-up samples (-8.5 ± 10.3) compared with the non-PSH group (4.7 ± 7.33; P = 0.024). However, neither BDNF nor EPC values had correlation with the 3-month outcome. Higher interleukin-6 at follow-up was associated with poor outcomes (modified Rankin Scale > 2) independently of PSH. Conclusion Post-stroke hyperglycaemia appears to be associated with a negative regulation of BDNF and a different reaction in EPC levels. However, neither BDNF nor EPCs showed significant mediation of the PSH association with IS outcome, and only higher interleukin-6 in the follow-up samples (72-96 h) was related to poor outcomes, independently of PSH status. Further studies are needed to achieve definite conclusions.

Ultrasound is a noninvasive technique that provides real-time imaging with excellent resolution, and several studies demonstrated the potential of ultrasound in acute ischemic stroke monitoring. However, only a few studies were performed using animal models, of which many showed ultrasound to be a safe and effective tool also in therapeutic applications. The full potential of ultrasound application in experimental stroke is yet to be explored to further determine the limitations of this technique and to ensure the accuracy of translational research. This review covers the current status of ultrasound applied to monitoring and treatment in experimental animal models of stroke and examines the safety, limitations, and future perspectives., This research was funded by the Carlos III Health Institute Health Care Research Fund grant number FIS PI16/01052 and cofunded by the European Regional Development Fund (ERDF)–Miguel Servet (CP15/00069, CPII20/00002 to María Gutiérrez–Fernández; CP20/00024 to Laura Otero–Ortega) and predoctoral fellowship (FI17/00188 to Mari Carmen Gómez–de Frutos, FI18/00026 to Fernando Laso–García) and the INVICTUS PLUS Spanish Network (RD16/0019/0005) of the Carlos III Health Institute (ISCIII).

The ‘cancer cell fusion’ theory is controversial due to the lack of methods available to identify hybrid cells and to follow the phenomenon in patients. However, it seems to be one of the best explanations for both the origin and metastasis of primary tumors. Herein, we co-cultured lung cancer stem cells with human monocytes and analyzed the dynamics and properties of tumor-hybrid cells (THC), as well as the molecular mechanisms beneath this fusion process by several techniques: electron-microscopy, karyotyping, CRISPR-Cas9, RNA-seq, immunostaining, signaling blockage, among others. Moreover, mice models were assessed for in vivo characterization of hybrids colonization and invasiveness. Then, the presence of THCs in bloodstream and samples from primary and metastatic lesions were detected by FACS and immunofluorescence protocols, and their correlations with TNM stages established. Our data indicate that the generation of THCs depends on the expression of CD36 on tumor stem cells and the oxidative state and polarization of monocytes, the latter being strongly influenced by microenvironmental fluctuations. Highly oxidized M2-like monocytes show the strongest affinity to fuse with tumor stem cells. THCs are able to proliferate, colonize and invade organs. THC-specific cell surface signature CD36+CD14+PANK+ allows identifying them in matched primary tumor tissues and metastases as well as in bloodstream from patients with lung cancer, thus functioning as a biomarker. THCs levels in circulation correlate with TNM classification. Our results suggest that THCs are involved in both origin and spread of metastatic cells. Furthermore, they might set the bases for future therapies to avoid or eradicate lung cancer metastasis., Research in the laboratory of EL-C was supported by “Fundación para la Investigación Biomédica La Paz Hospital” ((FIBHULP) and “Fundación Familia Alonso”.

Background Ultrasound is a safe, non-invasive and affordable imaging technique for the visualization of internal structures and the measurement of blood velocity using Doppler imaging. However, despite all these advantages, no study has identified the structures of the rat brain using conventional ultrasound. Methods A 13 MHz high frequency transducer was used to identify brain structures in the rat. The enlargement of the transcranial window was performed gradually using the ultrasound directly on the skin of the animal, then against the skull, then through a delimited craniotomy and finally through a complete craniotomy. Results Our results showed that ultrasound allowed the identification of cerebral ventricles and subarachnoid cisterns, as well as the analysis of real-time monitoring of cerebral blood flow in the main brain arteries of the rat. Comparison with existing methods Ultrasound is a tool with the potential to identify brain structures and blood vessels. In contrast to MRI, transcranial ultrasound is a fast, non-invasive, well tolerated and low-cost method and can be done at the bedside. Conclusion In the present study, we described an atlas of the main brain structures as well as the main vasculature in the rat using ultrasound. This technique could be applied in animal models of various neurological diseases.

Stroke is a major cause of morbidity, mortality, and disability. During ischemic stroke, a marked and prolonged rise of glutamate concentration in the brain causes neuronal cell death. This study explores the protective effect of a bioconjugate form of glutamate oxaloacetate transaminase (hrGOT), which catalyzes the depletion of blood glutamate in the bloodstream for ~6 days following a single administration. When treated with this bioconjugate, a significant reduction of the infarct volume and a better retention of sensorimotor function was observed for ischemic rats compared to those treated with saline. Moreover, the equivalent dose of native hrGOT yielded similar results to the saline treated group for some tests. Targeting the bioconjugate to the blood-brain-barrier did not improve its performance. The data suggest that the bioconjugates draw glutamate out of the brain by displacing homeostasis between the different glutamate pools of the body., Using a rodent model of ischemic stroke, Zahgmi et al. report on the neuro-protective effects of a bioconjugate form of the glutamate scavenger, glutamate-oxaloacetate transaminase (GOT). They found that a single dose of the bioconjugate was more effective in reducing the infarct size and improving motor function than the native GOT due to its higher and long lasting blood activity.

Extracellular vesicles (EVs) are a heterogeneous group of bilayer membrane-wrapped molecules that play an important role in cell-to-cell communication, participating in many physiological processes and in the pathogenesis of several diseases, including multiple sclerosis (MS). In recent years, many studies have focused on EVs, with promising results indicating their potential role as biomarkers in MS and helping us better understand the pathogenesis of the disease. Recent evidence suggests that there are novel subpopulations of EVs according to cell origin, with those derived from cells belonging to the nervous and immune systems providing information regarding inflammation, demyelination, axonal damage, astrocyte and microglia reaction, blood–brain barrier permeability, leukocyte transendothelial migration, and ultimately synaptic loss and neuronal death in MS. These biomarkers can also provide insight into disease activity and progression and can differentiate patients’ disease phenotype. This information can enable new pathways for therapeutic target discovery, and consequently the development of novel treatments. Recent evidence also suggests that current disease modifying treatments (DMTs) for MS modify the levels and content of circulating EVs. EVs might also serve as biomarkers to help monitor the response to DMTs, which could improve medical decisions concerning DMT initiation, choice, escalation, and withdrawal. Furthermore, EVs could act not only as biomarkers but also as treatment for brain repair and immunomodulation in MS. EVs are considered excellent delivery vehicles. Studies in progress show that EVs containing myelin antigens could play a pivotal role in inducing antigen-specific tolerance of autoreactive T cells as a novel strategy for the treatment as “EV-based vaccines” for MS. This review explores the breakthrough role of nervous and immune system cell-derived EVs as markers of pathological disease mechanisms and potential biomarkers of treatment response in MS. In addition, this review explores the novel role of EVs as vehicles for antigen delivery as a therapeutic vaccine to restore immune tolerance in MS autoimmunity.

Stroke is a major health problem worldwide. It has been estimated that 90% of the population attributable risk of stroke is due to risk factors such as aging, hypertension, hyperglycemia, diabetes mellitus and obesity, among others. However, most animal models of stroke use predominantly healthy and young animals. These models ignore the main comorbidities associated with cerebrovascular disease, which could be one explanation for the unsuccessful bench-to-bedside translation of protective and regenerative strategies by not taking the patient's situation into account. This lack of success makes it important to incorporate comorbidities into animal models of stroke in order to study the effects of the various therapeutic strategies tested. Regarding cell therapy, the administration of stem cells in the acute and chronic phases has been shown to be safe and effective in experimental animal models of stroke. This review aims to show the results of studies with promising new therapeutic strategies such as mesenchymal stem cells, which are being tested in preclinical models of stroke associated with comorbidities and in elderly animals.

Background: Pre-clinical studies on adipose tissue-derived mesenchymal stem cells (AD-MSC) suggest its efficacy and safety for ischemic stroke (IS). Our aim was to evaluate the safety of a single dose of AD-MSC administered intravenously in acute IS patients. Methods: A phase II, randomised, double-blind, placebo-controlled, single-center, pilot clinical trial. We included patients aged ≥ 60 years, with moderate to severe IS. Patients were randomly assigned (1:1 ratio) to receive either 1M cells/kg AD-MSC or placebo within the first two weeks after the onset of an IS. The primary outcome measure was safety (adverse events, neurological and systemic complications, and tumor developments). Secondary outcomes explored efficacy (modified Rankin Scale (mRS) and NIHSS). Here we report the preliminary results at 6 months of follow-up. EudraCT: 2011-003551-18; NCT01678534. Findings: Recruitment was stopped in December 2017 after including 19 out of the 20 planned patients. Six patients did not receive the study treatment (3 for technical reasons and 3 because they presented exclusion criteria after randomisation). The final sample was composed of 13 patients (4 in the AD-MSC and 9 in the placebo group). One patient from the placebo group died within the first 7 days due to sepsis. Serious adverse events at 6 months were reported in 5.1% of the AD-MSC group and in 6.6% in the placebo group. No injection-related adverse events or tumour developments were reported. After 6 months of follow-up there were no significant differences between the groups in median NIHSS scores [2.5 (IQR 1.75, 3.50) vs. 5 (IQR 4.0, 7.50)] and median mRS [3 (IQR 3.0, 3.25) vs. 4 (IQR 3.0, 4.0)]. Interpretation: Intravenous administration of AD-MSC within the first 2 weeks from IS onset seems to be safe at 6-months of follow-up and shows a trend toward improving neurological and functional recovery. Trial Registration: The study was registered at Clinicaltrials.gov, under the number NCT01678534. Funding Statement: Spanish Ministry of Health (EC2010/171). Declaration of Interests: B Fuentes reports grants from Spanish Ministry of Health and European Commission (Horizon2020 program), during the conduct of the study; other from Daichi-Sankyo, other from Bayer, other from BMS-Pfizer, other from Novonordisk, other from Novartis, outside the submitted work; M Gutierrez-Fernandez rports grants from Spanish Ministry of Health and European Commission (Horizon2020 program), during the conduct of the study; non-financial support from Cellerix/Tigenix, non-financial support from Histocell, outside the submitted work.AM Borobia reports grants from Instituto de Salud Carlos III, during the conduct of the study; personal fees from Mundipharma, personal fees from Menarini, outside the submitted work; and Principal Investigator in Clinical Trials for GSK and Daiichi Sankyo. E Diez-Tejedor reports grants from Spanish Ministry of Health and European Commission (Horizon2020 program), during the conduct of the study; non-financial support from Cellerix/Tigenix, non-financial support from Histocell, other from Daichi-Sankyo, other from Bayer, other from Sanofy Aventis, other from Novartis outside the submitted work. R Gutierrez-Zuniga, M Alonso de Lecinana, JC Martinez Avila, G Ruiz-Ares, MC Gomez-de Frutos, F Laso-Garcia and L Otero-Ortega report nothing to disclosure. Ethics Approval Statement: It was approved by the La Paz University Hospital Research Ethics Committee and by the Spanish Agency of Medicines and Health Products (EudraCT: 2011-003551-18).

Cell-based therapy has demonstrated safety and efficacy in experimental animal models of stroke, as well as safety in stroke patients. However, various questions remain regarding the therapeutic window, dosage, route of administration, and the most appropriate cell type and source, as well as mechanisms of action and immune-modulation to optimize treatment based on stem cell therapy. Various delivery routes have been used in experimental stroke models, including intracerebral, intraventricular, subarachnoid, intra-arterial, intraperitoneal, intravenous, and intranasal routes. From a clinical point of view, it is necessary to demonstrate which is the most feasible, safest, and most effective for use with stroke patients. Therefore, further experimental studies concerning the safety, efficacy, and mechanisms of action involved in these therapeutic effects are required to determine their optimal clinical use.

Approximately, 16 million strokes occur worldwide each year, causing 6 million deaths and considerable disability, implying an enormous social, individual health, and economic burden. Due to this high incidence, strategies to promote stroke recovery are urgently needed. Research into new therapeutic approaches for stroke has determined that intravenous administration of mesenchymal stem cells (MSCs) is a good strategy to improve recovery by amplifying mechanisms implicated in brain plasticity. Recent studies have demonstrated the efficacy of MSCs in stroke, with no need for them to reach the area of brain injury. Although the mechanisms by which they mediate restorative effects are still unknown, the evidence suggests that MSCs might use specialised communication by sending and receiving biological information included in elements called exosomes. Exosomes are nanosized extracellular vesicles released into physical environments, and they have recently been suggested to mediate restorative stem cell effects. Moreover, after stroke, exosomes can also be synthesised and released from brain cells, passing through the blood-brain barrier (BBB), and can be detected in peripheral blood or in cerebrospinal fluid. Thus, exosomes could possibly be biomarkers that reflect pathological progress and promote stroke recovery. This review discusses the translational aspects of MSC-derived exosomes and their various roles in brain repair and as circulating biomarkers in stroke.

Aim: To assess the efficacy of 3 doses of exosomes from adipose tissue derived human mesenchymal stem cells to identify the minimal effective dose to enhance brain repair and recovery after subcortical stroke in rats. Methods: Male and female Sprague-Dawley rats (250gr) were injected with endothelin-1 to induce subcortical stroke. 24h after stroke, exosomes were administrated by the tail vein. Study groups were: Sham (n=10): without stroke neither treatment; control: stroke+saline (n=8); stroke+low dose (50μg) (n=10); stroke+intermediate dose (100μg) (n=9); stroke+high dose (200μg) (n=10). We evaluated: motor function (Roger’s, Rotarod and Walking beam test) at 24h, 7 and 28d, lesion volume and tract connectivity were studied by magnetic resonance image at 24h and 28d, brain repair markers: GFAP (Glial Fibrillary Acidic Protein), MOG (Myelin Oligodendrocyte Glycoprotein), MBP (Myelin Basic Protein) by immunofluorescence at 28d. Results: Animals treated with 50μg, 100μg or 200μg of exosomes showed a significant improvement in functional evaluation compared to control (p Conclusion: Intravenous administration of different doses of exosomes (50μg, 100μg and 200μg) improves the functional recovery, tract connectivity and expression of brain repair markers. Low dose is as effective as intermediate and high doses. Therefore, 50μg of exosomes is the minimal effective dose to enhance brain repair and recovery in stroke.From a translational point of view, this dose decreases the cost and risk.

Extracellular vesicles (EVs) have emerged as important mediators of intercellular communication and as possible therapeutic agents in inflammation-mediated demyelinating diseases, including multiple sclerosis (MS). In the present study, we investigated whether intravenously administered EVs derived from mesenchymal stem cells (MSCs) from human adipose tissue might mediate recovery in Theiler’s murine encephalomyelitis virus (TMEV)induced demyelinating disease, a progressive model of MS. SJL/J mice were subjected to EV treatment once the disease was established. We found that intravenous EV administration improved motor deficits, reduced brain atrophy, increased cell proliferation in the subventricular zone and decreased inflammatory infiltrates in the spinal cord in mice infected with TMEV. EV treatment was also capable of modulating neuroinflammation, given glial fibrillary acidic protein and Iba-1 staining were reduced in the brain, whereas myelin protein expression was increased. Changes in the morphology of microglial cells in the spinal cord suggest that EVs also modulate the activation state of microglia. The clear reduction in plasma cytokine levels, mainly in the Th1 and Th17 phenotypes, in TMEV mice treated with EVs confirms the immunomodulatory ability of intravenous EVs. According to our results, EV administration attenuates motor deficits through immunomodulatory actions, diminishing brain atrophy and promoting remyelination. Further studies are necessary to establish EV delivery as a possible therapy for the neurodegenerative phase of MS., This study was supported by Red Española de Esclerosis Múltiple Grants RD12/ 0032/0008 and RD16/0015/0021 (sponsored by the Fondo de Investigación Sanitaria, Instituto de Salud Carlos III, Fondo Europeo de Desarrollo Regional [FEDER]) to C.G.

Recent studies have shown that blood glutamate grabbing is an effective strategy to reduce the excitotoxic effect of extracellular glutamate released during ischemic brain injury. The purpose of the study was to investigate the effect of two of the most efficient blood glutamate grabbers (oxaloacetate and recombinant glutamate oxaloacetate transaminase 1: rGOT1) in a rat model of intracerebral hemorrhage (ICH). Intracerebral hemorrhage was produced by injecting collagenase into the basal ganglia. Three treatment groups were developed: a control group treated with saline, a group treated with oxaloacetate, and a final group treated with human rGOT1. Treatments were given 1 hour after hemorrhage. Hematoma volume (analyzed by magnetic resonance imaging (MRI)), neurologic deficit, and blood glutamate and GOT levels were quantified over a period of 14 days after surgery. The results observed showed that the treatments used induced a significant reduction of blood glutamate levels; however, they did not reduce the hematoma, nor did they improve the neurologic deficit. In the present experimental study, we have shown that this novel therapeutic strategy is not effective in case of ICH pathology. More importantly, these findings suggest that blood glutamate grabbers are a safe treatment modality that can be given in cases of suspected ischemic stroke without previous neuroimaging.

Blocking axonal growth inhibitor NogoA has been of great interest for promoting axonal recovery from neurological diseases. The present study investigates the therapeutic effects of blocking NogoA, inducing functional recovery and promoting white matter repair in an experimental animal model of stroke. Adult male rats were subjected to white matter injury by subcortical ischemic stroke. Twenty-four hours after surgery, 250 ug of anti-NogoA or anti-IgG-1 were administered through the tail vein. The quantity of NogoA protein was determined by immunohistochemistry in the brain and peripheral organs. In addition, functional status, lesion size, fiber tract integrity, axonal sprouting and white matter repair markers were analyzed. Moreover, an in vitro study was performed in order to strengthen the results obtained in vivo. A lower quantity of NogoA protein was found in the brain and peripheral organs of the animals that received anti-NogoA treatment. The animals receiving anti-NogoA treatment showed significantly better results in terms of functional recovery, fiber tract integrity, axonal sprouting and white matter repair markers compared with the control group at 28 days. White matter integrity was in part restored by antibody-mediated inhibition of NogoA administration in those animals that were subjected to an axonal injury by subcortical stroke. This white matter restoration triggered functional recovery.

Exosomes are gaining importance because they show great promise in therapeutic applications for several diseases. Particularly in stroke, exosomes derived from mesenchymal stem cell (MSC) therapy work as paracrine effectors responsible for promoting neurovascular remodeling and functional recovery. Adult male rats were subjected to intracerebral hemorrhage (ICH) by intrastriatal injection of collagenase type IV; 24 h after surgery, MSC-derived exosomes were administered through the tail vein. The rats were euthanized at 7 or 28 days after treatment. Functional evaluation, lesion size, fiber tract integrity, axonal sprouting and white matter repair markers, biodistribution of exosomes and secretome proteomics were analyzed. DiI-labeled exosomes were found in the brains of the ICH-treated group and in the liver, lung and spleen. Animals receiving treatment with exosomes showed significantly better results in terms of functional recovery, lesion size, fiber tract integrity, axonal sprouting and white matter repair markers compared with the control group 28 days after stroke. Proteomics analysis of the exosomes identified more than 2000 proteins that could be implicated in brain repair function. In conclusion, white matter integrity was partly restored by exosome administration mediated by molecular repair factors. Exosomes as a treatment could be a heterogeneous process by nature and presents many factors that can influence brain plasticity in an adaptable and versatile manner. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study has been partially supported by grants from PS15/01318 and INVICTUS (RD12/0014) (Spanish Neurovascular Network), Miguel Servet (CP15/00069 to Marıa Gutierrez-Fernandez) and a Sara Borrell postdoctoral fellowship (CD12/00706, to Laura Otero-Ortega) from the Research Institute Carlos III, the Spanish Ministry of Science and Innovation and the European Regional Development Fund. This study was also co-funded within the Roche Farma project. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. Sí

Mesenchymal stem cells have previously been shown to mediate brain repair after stroke; they secrete 50-100 nm complexes called extracellular vesicles (EVs), which could be responsible for provoking neurovascular repair and functional recovery. EVs have been observed by electron microscopy and NanoSight, and they contain associated proteins such as CD81 and Alix. This purified, homogeneous population of EVs was administered intravenously after subcortical stroke in rats. To evaluate the EVs effects, we studied the biodistribution, proteomics analysis, functional evaluation, lesion size, fiber tract integrity, axonal sprouting and white matter repair markers. We found that a single administration of EVs improved functional recovery, fiber tract integrity, axonal sprouting and white matter repair markers in an experimental animal model of subcortical stroke. EVs were found in the animals' brain and peripheral organs after euthanasia. White matter integrity was in part restored by EVs administration mediated by molecular repair factors implicated in axonal sprouting, tract connectivity, remyelination and oligodendrogenesis. These findings are associated with improved functional recovery. This novel role for EVs presents a new perspective in the development of biologics for brain repair., This study has been partially supported by grants from PS15/01318 and INVICTUS (RD12/0014) (Spanish Neurovascular Network), Miguel Servet (CP15/00069 to María Gutiérrez-Fernández) and a Sara Borrell postdoctoral fellowship (CD12/00706, to Laura Otero-Ortega) from Research Institute Carlos III, Ministry of Science and Innovation of Spain and European Regional Development Fund

Angiotensin type 1 receptor blockers (ARBs) have induced improved functional recovery and reduced infarct volume in experimental animal models of stroke. Clinical data have indicated a positive correlation between prestroke treatment with ARBs and reduced stroke severity and better outcomes; however, the mechanisms of these beneficial effects are not yet well understood. This study compares the protective and possible reparative effects of continuous oral treatment with olmesartan (OLM) with OLM pretreatment and withdrawal after permanent middle cerebral artery occlusion (pMCAO) in rats. Fifty-two Sprague-Dawley rats were randomly assigned to five groups: MCAO–/OLM (OLM 10 mg/kg/day for 14 days after infarct), MCAOOLM/OLM (OLM 10 mg/kg/day for 7 days before and 14 days after infarct), MCAOOLM/– (OLM 10 mg/kg/day for 7 days before infarct), sham, and control. We analyzed functional recovery; lesion size; cell death; expression of the pro-oxidant enzyme NADPH oxidase 4 (NOX-4); isolectin-B4; and repair markers such as glial fibrillary acidic protein, vascular endothelial growth factor (VEGF), and brain-derived neurotrophic factor (BDNF). All of the OLM-treated groups showed significantly better functional scores and reduced infarct sizes and cell death compared with the control group 14 days after pMCAO. Levels of NOX-4, VEGF, and BDNF were significantly lower in the brains of the MCAOOLM/OLM and sham groups compared with the other groups. OLM treatment improved functional recovery and reduced lesion size and cell death after cerebral ischemia. Only the continuous administration of OLM before and after stroke reduced oxidative stress levels, with better tissue preservation, without triggering brain repair marker activation. © 2014 Wiley Periodicals, Inc.

Patients with acute ischemic stroke (AIS) suffer from infections associated with mortality. The relevance of the innate immune system, and monocytes in particular, has emerged as an important factor in the evolution of these infections. The study enrolled 14 patients with AIS, without previous treatment, and 10 healthy controls. In the present study, we show that monocytes from patients with AIS exhibit a refractory state or endotoxin tolerance. The patients were unable to orchestrate an inflammatory response against LPS and expressed three factors reported to control the evolution of human monocytes into a refractory state: IL-1R–associated kinase-M, NFkB2/p100, and hypoxia-inducible factor-1α. The levels of circulating mitochondrial DNA (mtDNA) in patients with AIS correlated with impaired inflammatory response of isolated monocytes. Interestingly, the patients could be classified into two groups: those who were infected and those who were not, according to circulating mtDNA levels. This finding was validated in an independent cohort of 23 patients with AIS. Additionally, monocytes from healthy controls, cultured in the presence of both sera from patients and mtDNA, reproduced a refractory state after endotoxin challenge. This effect was negated by either a TLR9 antagonist or DNase treatment. The present data further extend our understanding of endotoxin tolerance implications in AIS. A putative role of mtDNA as a new biomarker of stroke-associated infections, and thus a clinical target for preventing poststroke infection, has also been identified.

Introduction: Extracellular vesicles such as exosomes has opened a new field of research. Exosomes are able to transfer DNAs, mRNAs, microRNAs, non-coding RNAs, proteins, trophic factors and lipids associated with brain plasticity enhancement after stroke. Aim: To investigate white matter repair after exosomes administration in two experimental models of subcortical stroke: ischemic and hemorrhage. Material/Methods: Subcortical ischemic stroke was induced by Endothelin-1 and Collagenase IV was used to induce subcortical hemorrhagic stroke into striatum. Intravenous exosomes or saline only were administrated at 24h after cerebral infarct as treatment. Exosomes were isolated from culture of adipose mesenchymal stem cell and they were characterized by Nanoshight, Electronic microscope, Western blot and Immunofluorescence. Proteins contained into exosomes were analyzed by Orbitrab. We analyzed functional recovery by Rotarod, beam walking and Rogers tests. Lesion volume and tract connectivity were studied by magnetic resonance image. Anterograde and retrograde tracers were used to analyze axonal sprouting. Myelin formation was analyzed by cryomielin. Results: Proteomics analysis of exosomes identified more than 1400 proteins, many of them involved in intercellular communication. DiI labeled-Exosomes were detected in brain and peripheral organs (liver, lung and spleen). After 28 days, treated groups showed smaller functional deficit compared to control groups in both hemorrhagic and ischemic models. Moreover, treated group showed an increase in tract connectivity at 7 and 28 days compared to control groups. Also, animals which received exosomes showed an increase axonal sprouting and myelin formation at 28 days after stroke in both hemorrhagic and ischemic stroke. The treated groups also showed higher levels of white matter-associated markers in the injured area than the control groups. Conclusion: White matter integrity in different subcortical strokes is in part restored by exosomes treatment, probably mediated by repair molecular factors implicated in axonal sprouting, remyelination and oligodendrogenesis. These findings are associated with improved functional recovery in both kinds of strokes.

Ultrasound-targeted microbubble destruction (UTMD) has been shown to be a promising tool to deliver proteins to select body areas. This study aimed to analyze whether UTMD was able to deliver brain-derived neurotrophic factor (BDNF) to the brain, enhancing functional recovery and white matter repair, in an animal model of subcortical stroke induced by endothelin (ET)-1. UTMD was used to deliver BDNF to the brain 24 h after stroke. This technique was shown to be safe, given there were no cases of hemorrhagic transformation or blood brain barrier (BBB) leakage. UTMD treatment was associated with increased brain BDNF levels at 4 h after administration. Targeted ultrasound delivery of BDNF improved functional recovery associated with fiber tract connectivity restoration, increasing oligodendrocyte markers and remyelination compared to BDNF alone administration in an experimental animal model of white matter injury.

Introduction: our primary objective was to analyze the efficacy of a Telestroke system in terms of an increase in the number of patients treated with intravenous thrombolysis (IVT) and a shorter door-to-needle time, in the metropolitan area of Madrid, Spain. Our secondary objective was to analyze the safety of Telestroke in terms of mortality and symptomatic hemorrhagic transformation (SHT). Methods: prospective observational cohort study: 1) cohort exposed to Telestroke: acute ischemic stroke patients attended at Infanta Sofia University Hospital (community hospital) connected by Telestroke with the Stroke Center at La Paz University Hospital; 2) Non-exposed cohort: acute stroke patients who are attended at Severo Ochoa University Hospital (community hospital) connected by phone with the Stroke Center at Ramon y Cajal University Hospital. The number of patient attended, number of IVT, times (min), 3-months outcome (mRS), the number of unnecessary transfers and safety parameters (mortality and SHT by ECAS III criteria) were recorded. We analyzed the first 34 months of the Telestroke (March 2011-december 2013). Results: in the Telestroke cohort the system was activated in 59 patients, being stroke code in 42 cases. In the non-exposed cohort 45 phone calls were made, being stroke code in 42 cases. In the Telestroke cohort, IVT were administrated in 61.9% (26/42) of patients whereas in the non-exposed only 28.6% (12/42) received this treatment (P=0,002). The door-to-needle time was shorter in Telestroke cohort than in the non-exposed cohort (mean [SD]) (86.9 [41.7] vs. 149.7 [68.2], P=0.001). The 3-month outcomes were better in the Telestroke cohort (mRS 0-3: 92.9% vs. 73.8%, P=0.038). Mortality (4,8% vs. 4.8%) and SHT (0% vs. 4.8%) were similar in both groups (P = NS). In addition, there were fewer unnecessary secondary transfers in the Telestroke cohort (4.3% vs. 20%, P=0.027). Conclusion: the implementation of a Telestroke system in a metropolitan area is effective and safe, increasing the number of IV thrombolysis and reducing the door-to-needle times. Furthermore, the Telestroke reduces the number of unnecessary secondary transfers.