神經(jīng)保護(hù)劑及腦卒中的治療策略

1、內(nèi)容1. 神經(jīng)保護(hù)治療的概念 玄神經(jīng)保護(hù)劑的現(xiàn)狀3.敗SB勒紙劃曲墓猜除劑5.神經(jīng)ftTlBO腸 鼠神經(jīng)裸護(hù)劑蒯谿痛藥急性缺血性卒中References: 1. Lipton R Ischemic cell death in brain neurons Physiological Reviews Oct 1999; vol. 79; 1431-1568. 2. Lo EH, Dalkara X Moskowitz MA. Mechanisms, challenges and opportunities in stroke Nat Rev Neurosci. 2003;4(5):399-415缺

2、血性卒中的病理生理生物化學(xué)級鏈反應(yīng)References: 1. Dirnagl U, ladecola C, Moskowitz MA. Pathobiology of ischaemic stroke: an integrated view.Trends Neurosci. 1999;22(9):391-7. 2. Lee JM, Grabb MC, Zipfel GJ, Choi DW. Brain tissue responses to ischemia. J Clin Invest. 2000;106(6):723-31.神經(jīng)保護(hù)可以改善臨床預(yù)后其中一個(gè)途徑使減少自由基損害"

3、急性缺血性卒中缺血級鏈反應(yīng)|再灌注級鏈反應(yīng)谷氨酸釋放NMDA/AMPA受體活化去極化鈣離子增加1-”1自由基增加自由基增加神經(jīng)細(xì)胞死亡References: 1. Bright, R, Mochly-Rosen D The role of protein kinase C in cerebral ischemic and reperfusion injury. Stroke 2005;36(12):2781-90. 2. Lipton R Ischemic cell death in brain neurons. Physiol Rev. 1999;79(4):1431-568.神經(jīng)保護(hù)和神經(jīng)

4、恢復(fù)神經(jīng)保護(hù)Neuroprotection神經(jīng)恢復(fù)Neurorestoration靶向缺血半暗帶全部有功能的組織時(shí)間窗0-24小時(shí)，或許更長24小時(shí)以后，數(shù)周？數(shù) 月？目的控制分子事件調(diào)節(jié)功能組織的活動神經(jīng)保護(hù)劑的作用有神經(jīng)保護(hù)缺血損害減輕無神經(jīng)保護(hù)永久缺血性損害Reference: 1. Fisher M. The ischemic penumbra: identification, evolution and treatment concepts. Cerebrovasc Dis. 2004;17(suppl l):l-6.<OscheTnia>Energy failureGL

5、*.iatereleaseInflammatoryresponsedeg y izafion* ' 嚀A & I f I_* palliate b：OAo3mGluRLeucocyte adhesionMH? Nitric oxide:synthaseFree radicalformationL» CELL DEATH 斗卜 Proteolysis:Membrane & :cytoskeletal :damage : I Free radicaF formationLipolysis1 fomriatioii內(nèi)容1. 神經(jīng)保護(hù)治療的概念2. 神經(jīng)保護(hù)劑的現(xiàn)狀3

6、. 從失敗到成功 紙自曲葩除劑気神經(jīng)啲eww $神經(jīng)棵護(hù)劑齣藥神經(jīng)保護(hù)應(yīng)用的范圍神經(jīng)外科心臟外科一 Beating heart心臟驟停頸動脈治療創(chuàng)傷卒中（缺血性和出血性）潛在治療1. 縮短缺血時(shí)間2. 減少細(xì)胞內(nèi)鈣離子濃度3. 減少細(xì)胞內(nèi)鈉離子濃度4. 阻斷谷氨酸作Jtl Block effects of glutamate5. 抑制自由基Trap free radicals 6抑制PARP活性7.阻斷caspase活性 9.改變細(xì)胞膜流動性 10 降低組織溫度阻斷白細(xì)胞黏附神經(jīng)保護(hù)劑:夭折的嬰兒動物實(shí)驗(yàn)有效臨床試驗(yàn)無效卒中神經(jīng)保護(hù)治療是否 是基礎(chǔ)科學(xué)工作者編織 的夢？Is Neuroprot

7、ective Stroke Therapy Just a Fanasy Invented by Basic Scientists?缺血神經(jīng)保護(hù)劑：路在何方?Consummating the Marriage Between the Laboratry and BedsideLaboratory<3Hrs12-24Hrsdelay1TischemiaRx>on$et TTinfarctbehaviorVOlUiYIA(standardized lesion)Clinical<3Hrs12-24 Hrsdelayi$Ch$i1riid Rx onset (standardized

8、le&ion by DW1or clinical criteria KIHSS)New Pharmacological agents'Cocktail approachT infarct volume (OW1. MR I)globalstatistic緲 HSS,earthol,Rankin.QOL)Huston Medical SchoolUbiquitin-Proteasome ComplexSubstrate protein19S regulatory particle(b) Complete proteasome(a) 20S core particleUbiquit

9、inProteasome ComplexPolyubiquitin protein interacts with proteasomeUbiquitin-Proteasome Complexubiquitincoo-|amp|ATPubiquitin- activating en zymes-c=o(B)E-amino group on lysine side chainbin ding to ubiquiti n ligaseE2-SHE3ubiquitin ligaseprimed w讓hubiquiti nE2E3E3first ubiquitin chain added to targ

10、et proteintarget protein bound to ubiquitin ligasedegradati onsignal ontarget protein(C)target proteinwithmultiubiquitinchai nFigure 687 part 2 of 2. Molecular Biology of the Ceil, 4th Edition.Following 15 min global cerebral ischemia, protein aggregates are ubiquitin labeledSham30min4h24h72hFig. 4

11、Double staining confocal microscopic images obtained with the anti-ubiquitin antibody (green) and propidium iodide (red) in CAI (upper panels) and DG (lower panels) regions. Sections are shown from sham-control and from 30 min, 4, 24 and 72 h of reperfusion after 15 min of ischemia Overlay of the gr

12、een and red creates a yellow color. The labeling pattern is clearly altered from the even distribution tO the aggregates during reperfusion.Hu 或創(chuàng)，丄 Neurosci, 2000, 20:3292Prateasome InhitetoisClass ol CixnpoandMtechanism of ActBonChemical StxucturttAtoJu-aU/ Occur 蝕LactaqfstinProd rug tar the p-laci

13、one structurehnds cxivalentiy t(i subunit /i5 oi mamnnniiasi proteasocnes also inhituis cathep引ns A and tnpeptidyt peptidase IIAciacifMwnjcmAklaMnoneinhitxts the ChTL actwity oi the proteasomewthout effects on caBiepsin 6. Ktioiiated trypsin, and inhi&ttea cnynnmrypsn and. io a fesser extent. ca

14、lpanEponemycinbinds coralEfitly the (<5, p5i, arad pls catalytc sutwnrts tf the 2OS pfutoasome and sBtectivdy intibits the 5 najw pcoleacsoiTM! proteolytic activities at dtferen? ratersEipaxomyonCatne<iadinbinds cxjvalerrtly to th© p5i. 5, |K2it and fl2 cataljFtic subunits of the 2CS prcr

15、tEasorne and nhtiits primant)» the ChTL activity; does oat inhibt other urotcasEs. lie. caJpain. casliepsiii B. papari. irypsim chyniolrypsinl a! GOTcentratiuns up to 50 mol'Ln highly bsac arginipralinp-neri peptise, reumitxy Dinds to me a7 submit of the proleameH41-R-R-P-R.p.p-r-L-p.R-P-RP

16、 -P-F-F-P PRlPPFMPLGFPPRFPPR/P OHProteasome inriiMois Ctass oi CompoundMechanism oi ActionChenxsl SlruetureSynfhet)ePptde mimiGNo specific 腫 teasonc nhibrtcxsno specific prote彌me nhibitixsi.N-519Symwc那川 similar to laclacystmrwte Win(K咖他nucieophife Oy of Thr1 on the 兩 subunitMG-13JInpeptid aldenyoeco

17、mmo niy used rersable inhibitor oi the ChTL arbsty of the proleasome; aiso inhibrts cathepsins and calp3tnsCEP-1612Dipcptidyl alifchyoe forms ruvarsibte covalent aJikiGte with ths proixised calalytk: nucleophile. Oyal Tlir* on l he 0-subund: also inhitMls rfsosomal aoo Ca ?-aa»vated proteasesCV

18、T-634Dipeptide tenzarnidemhibrts ChTL activityBorte?txmb itnnnBrlyVeccade PS-341)Dip印t)刨 bonxilc acid mhtbflwsinhibits ChIL activity approve© Dy FDA for t rear rent M multiplB myetoma and other nakgnancies2-amino3enzy1stabne( fonmerty NVP-AFB340 and WP-AFD314Boromc acida structixe-based opt<

19、nization approachderivaf/esimproved ttie potRncy at th<s serses wttithe mast poten： ccmpoond achieving an ICM vakie o1 7 nmobl against the ChR activity in dMtkin, these <x)mp(x)nds dcfnonstrated goed selectivity against ttic PGPH and TL proteasomal activities 掘II IC刃 *aiies>20 卩 moVLiVirTI

20、sjlfone- tri peptidesVinyl suHoob mowties al InpeptiOescompetitivE nhibitixs that are largely specific lor mdividual fi subunits of the 205 pfiXcasome bul also mliibil intracellular cvrtcine pf-otcascsRitcnavirhv-1 proiease mhibrtcraiw a 說亦 KhvnxraTOiar inhiOitcx ot the chyniMrjptJC actrtity of the

21、?0S proteafH)(ne by binding the pr-oteasonie subunit and p5i血管保護(hù)治療aiLUHosACUTESUMUTghdkhe1腦餘誡職殆|加im ijWkw*-伽喚咲沏荒； 際誡朋.11®5 agim 觀也鍛aw啊魄啊呦也頃b鉀陰"期7:New discovery compoundsSynthesis and Screening10,000Pre-clinical development appraisal6,000Phase I50Sub-acute toxicity20Phase IIA (PoC)15Chronic

22、 toxicity10Clinical Phase II5Carcinogenicity3PLA1Market1Post Market?Probability of Success = 1 in 10,000COST PER COMPOUND $US 1 BN內(nèi)容1. 神經(jīng)保護(hù)治療的概念2. 神經(jīng)保護(hù)劑的現(xiàn)狀3. 從失敗到成功自1曲墓猜除劑反神經(jīng)葆護(hù)劑的#®舷神經(jīng)保護(hù)劑的誤區(qū)(Pitfalls)臨床前研究的時(shí)窗極短，而臨床研究的時(shí)窗較長 臨床前治療靶區(qū)是半暗帶，而臨床試驗(yàn)則不是|離聖溫療偏向?qū)屹|(zhì)的保護(hù)，而臨床不針對特定的 尚不清楚確切療程 臨床前主要依據(jù)早期預(yù)后，而臨床是遠(yuǎn)期評價(jià)

23、卒中模型為同質(zhì)性,而人類卒中為異質(zhì)性 預(yù)后測量方法比實(shí)際療效更重要療效判定主要依據(jù)梗死面積，而臨床主要用小規(guī)模試驗(yàn)回答大規(guī)模試驗(yàn)要回答的問題內(nèi)容1. 神經(jīng)保護(hù)治療的概念2. 神經(jīng)保護(hù)劑的現(xiàn)狀3. 從失敗到成功自由基清除劑Oxygen MetabolismI2RBC Hb-OlCells11111 1PSNOSMembranePeroxisomeSERMitochondria eC hv1IOxidasesPHS/ 'P-450 transportMPx°2O2K .o2°2NO-I44 oIh2o2 no-IPGso/' HOCI-h2o2LTs爲(wèi)6H2O

24、6缺血半暗帶超氧化物（自由基）增加（218）超氧化物化學(xué)發(fā)光計(jì)數(shù)腦中動脈缺血PetersO.etal.,1996缺血1小時(shí)后再灌注鈣超載導(dǎo)致自由基產(chǎn)生促氧化酶*- 一氧化氮合成酶-環(huán)氧化酶，腺卩票吟脫氫酶， 腺瞟吟氧化酶，NADPH氧化 酶-髓過氧化酶和單氨氧化酶References: 1. Chan PH. Reactive oxygen radicals in signaling and damage in the ischemic brain J Cereb Blood Flow Metab. 2001;21(l):2-14. 2. Schild L, Reiser G Oxidativ

25、e stress is involved in the permeabilization of the inner membrane of brain mitochondria exposed to hypoxia/reoxygenation and low micromolar Ca2+FEBS J. 2005;272(14):3593-601.自由基可以損害細(xì)胞和DNAMMP活化細(xì)胞膜破壞自由基線粒體破壞DNA氧化損傷細(xì)胞處理過程失調(diào)References: 1. Lipton R Ischemic cell death in brain neurons Physiological Revi

26、ews Oct 1999; vol. 79; 1431-1568. 2. Dirnagl U, ladecola C, Moskowitz MA. Pathobiology of ischaemic stroke: an integrated view. Trends Neurosci. 1999;22(9):391-7自由基損傷線粒體Free radicals o CMum < Cytochrome CReferences: 1. Dirnagl U, ladecola C, Moskowitz MA. Pathobiology of ischaemic stroke: an inte

27、grated view Trends Neurosci. 1999;22(9):391-7. 2. Sasaki C, Kitagawa H, Zhang WR, Warita H, Sakai K, Abe K Temporal profileof cytochrome c and caspase-3 immunoreactivities and TUNEL staining after permanentmiddle cerebral artery occlusion in rats. Neurol Res. 2000;22(2):2238.缺血/再灌注使自由基產(chǎn)生增加Stroke. 20

28、04;35:1449-1453Stroke. 2004;35:1449-1453I3NT神經(jīng)細(xì)胞膠質(zhì)細(xì)胞MAP-25FAPCD3440 g)hj內(nèi)皮細(xì)胞a)b)c)MAF-2GFAPCD-34e)3-NTMergrtl .Stroke. 2004;35:1449-1453SAINT I outcomesmRSScora 0 1 2 H 34 Sor DeathProportionofPatkiritsIn tha AcKp Ripufaiiofi (%)ImprovMMntin4J2,422氏 7OlONXM59 右 nh (%PKortiMi of Patients In tho Pr-Ra

29、tocol RopuUion (%)ImprwwwHtiit 4.93.1244.513NXY-059 Gnm> (%Subgroup interactions with primaryendpoint not sigrdficant Treatme nttime p=0.92 Treatme ntage p=0.62 Treatmentseverity p=0.72 Treatme ntalteplasep=0.93 Treatme ntdiabetes p 二 0.98 Treatmentglucose p=0.27etc口口 口口(NINDS definition)npt ICH

30、pt ICHPlacebo, n=249 NXY, n=240SAINT-I 結(jié)論 The administration of NXY-059 within six hours after the on set of acute ischemic stroke significantly improved the primary outcome (reduced disability at 90 days), but it did not sign訐icantly improve other outcome measures, including neuroloqic functioning

31、as measured by the NIHSb score. Adcfftional research is needed to con firm whether NXY-059 is ben eficial in ischemic stroke.Treatment Interactions withImportant CovariatesVariableOdds Ratio (95% Cl)<4 h>4 hrUse of alteplaseNo use of alteplaseNIHSS 6-9NIHSS 10-14NIHSS 15-19NIHSS >200；1.0Pla

32、cebo BetterNXY-059 Better0.91 (0.78-1.06)0.98 (0.79-1.22)0.90 (074-1.08)0.97 (0.82-1.15)0.85 (0.69-1.05)0.92 (0.74-1.13)1.14 (0.83-152)1.00 (071-1.41)Primary Outcome at 90 Days According tothe Score on the Mod訐ied Rankin ScaleScore 0 1 2 3 4 5 or DeathPlacebo10318.414715,017.42421Jr1tJ r1NXY-0599.81

33、7.614.014.717.826.1Proportion of Patients in theEfficacy Population (%)SAINT-II NXY-059 is ineffective for the treatment of acute ischemic stroke within 6 hours after the on set of symptoms.國內(nèi)II期臨床結(jié)果入組病例229例，實(shí)際完成病例213例ESS評分：神經(jīng)功能缺損評分、有效率在第7天、14天、21天均有顯著性差異，且隨著 時(shí)間延長差異逐步明顯；ADL評分：日常生活活動量表評分、有效率在第7天、14天、

34、21天、90天均有顯著性差 異，且隨著時(shí)間延長差異逐步明顯復(fù)旦大學(xué)附屬華山醫(yī)院，第二軍醫(yī)大學(xué)長征醫(yī)院，浙江大學(xué)醫(yī)學(xué)院第二附屬醫(yī)院，江蘇省人民醫(yī)院南京醫(yī)科大學(xué)附屬腦科醫(yī)院，依達(dá)拉奉治療急性腦梗塞隨機(jī)、雙盲、疊加、對照、多中心臨床試驗(yàn)日本III期臨床依達(dá)拉奉組對照組<24hr最終綜合改善率73.8%（31M2 例）25.6%（10/39 例）安全性85.7%（36M2 例）76.9%（30/39例）有效率69%（29/42例）20.5%（8J39 例）最終綜合改善率64-8%32.0%<72hr（81 例 H25 例）（40 例 H25 例）三期臨床有效!Cerebrovascular

35、Diseases2003; 15（3）:222-9Effectofa no velfreeradicalscave nger;edarav on e（MCI-186）,or:222-9utebraininfarction.Ra ndpmiz 劉pipe 頤 o-contglled,double-bljnd 期aravone Acute Infarction Study Group, Cerebrovascular Diseases 2003;15（3）1. 神經(jīng)保護(hù)治療的概念2. 神經(jīng)保護(hù)劑的現(xiàn)狀3. 從失敗到成功4. 自由基清除劑神經(jīng)保護(hù)劑的分層用藥 低神經(jīng)伽湎»10藥10flow

36、 disturb sincewooa>6ELL!ep BC2XCD-CBlledswoUHXMTBA-U- 11 I I .1 IUBMZJLX* 3“右厶兒”-W.J占 i 'rapid:O2 depletionI energy怕阻芒terminal depolanzation ion horneustasifefaikHesecond 審 y: excitoioxicilySD-like depDiarization&inflammation apoptosisminuteshoursweeks10DWIPeThrombolysisPost-ThrombolysisD

37、ay 7ADCT2再灌注增加自由基的產(chǎn)生Free radicalsReferences: 1. Schild L, Reiser G Oxidative stress is involved in thepermeabilization of the inner membrane of brain mitochondria exposed to hypoxia/reoxygenation and low micromolar Ca2+. FEBS J. 2005;272(14)3593-601. 2. Dirnagl U, ladecola C, Moskowitz MA. Pathobiol

38、ogy of ischaemic stroke: an integrated view. Trends Neurosci. 1999;22(9):391-7. 3. Lo EH, DalkaraMoskowitz MA. Mechanisms, challenges and opportun讓iesin stroke Nat Rev Neurosci. 2003;4(5):399-415.Stroke 2001;32:1079-1084血管再通時(shí)間與出血轉(zhuǎn)化有出血轉(zhuǎn)化 無出血轉(zhuǎn)化血管灌注后的高灌注綜合征Stroke 2001;32:1079-1084內(nèi)容1. 神經(jīng)保護(hù)治療的概念2. 神經(jīng)保護(hù)劑

39、的現(xiàn)狀3. 從失敗到成功4. 自由基清除劑5. 神經(jīng)保護(hù)劑的分層用藥神經(jīng)保護(hù)劑的聯(lián)合用藥Emerging TherapiesSection Editors: Marc Fisher, MD? »n(l Antoni Diivalos, MI)Toward a Multimodal Neuroprotective Treatment of StrokeAndieas Rogalewski, MD; Aiwin Schneider, MD: E. Bernd Ringelstein, MD; Wolf-Riidiger Schabitz, MDBackgrouttd and Pur po

40、seStroke remains a common medical problem with ijnpoitance attributable to the demographic changes in industrialized societies.Summary ofUeviewAfter years of setbacks, acute stroke therapy ha$ finally emersjed, including thrombolysis with tissue plasminogen activator (t-PA). However, t-PA treatment

41、is limited by a nairow time window and side effes, so that only 3% of all stroke patients receive thrombolysis Uniinodal targeting of key events in stroke pathophysiolo was not effective in providing long-term benefits, leading to negative results in previcnis clinical neurDprcitective stroke trials. A successful future stroke tlierapy should appro acli multiple pathophysiologic al jnechanisms besides revascularization at once, including reduction of t-PA-related side effects, prevention of cell death, stimulation of nenroregen