Neuroprotective and Restorative Potential of Remote Ischemic Conditioning Following Stroke

Abstract

Remote ischemic conditioning (RIC) is a noninvasive procedure where blood flow to a limb is repetitively reduced, sometimes called an “exercise memetic”. RIC delivered before (pre-RIC) or after (post-RIC) stroke is reportedly neuroprotective in preclinical stroke models. A review of the preclinical RIC literature revealed that studies almost exclusively use male subjects and a single stroke model (MCAO) that produces a large injury (~34% of hemisphere). To improve clinical translation, efficacy should be demonstrated in multiple stroke models and both sexes. Furthermore, the restorative potential of RIC (delivered past the neuroprotection window) to improve stroke recovery remains to be investigated. In male and female Sprague-Dawley rats (n=129) a standardized session (5min inflation, 5min deflation, 4 repetitions) of RIC was delivered using a pressurized cuff on the hindlimb. RIC was either delivered once 18h before, once 4hr acutely after or daily for 28 days beginning day 5 after endothelin-1 (ET-1) stroke. Infarct volumes were assessed 24hrs after stroke using MRI. To determine if RIC efficacy varied across stroke size, a hierarchical cluster analysis was used to divide rats into subgroups based on stroke size (small/large). RIC was effective in ET-1 which produced smaller strokes (“small”:5.2%, “large”:18.0% of hemisphere) than MCAO (~34%). This is more comparable to injury sizes seen clinically (4.5-14.0%). “Small” (42±4mm3) strokes were reduced by 39% (p=0.010, d=0.29) and “large” (146±8mm3) strokes were reduced by and 35% (p<.00001, d=1.41). Pre-RIC reduced infarct volume by 41% (p=<0.0001, d=0.92) versus 29% (p=0.009, d=0.43) in post-RIC. Interestingly, RIC is more effective in males, with double the infarct volume reduction of 46% (p<0.0001, d=0.94) compared with 23% (p=0.013, d=0.42) in females. Although RIC did not show restorative potential to improve motor stroke recovery, RIC is neuroprotective now with stronger clinically relevant evidence. RIC is effective across stroke models, stroke sizes and sex. Application of RIpreC to prevent stroke following a transient ischemic attack or recurrent stroke (especially in males with “large" strokes) would have the greatest potential.