Ladecola C, Anrather J. (2012)

review
The immunology of stroke: from

mechanisms to translation
Costantino Iadecola & Josef Anrather
Immunity and inflammation are key elements of the pathobiology of stroke, a devastating illness second only to cardiac ischemia
as a cause of death worldwide. The immune system participates in the brain damage produced by ischemia, and the damaged
brain, in turn, exerts an immunosuppressive effect that promotes fatal infections that threaten the survival of people after stroke.
© 2011 Nature America, Inc. All rights reserved.
Inflammatory signaling is involved in all stages of the ischemic cascade, from the early damaging events triggered by arterial
occlusion to the late regenerative processes underlying post-ischemic tissue repair. Recent developments have revealed that
stroke engages both innate and adaptive immunity. But adaptive immunity triggered by newly exposed brain antigens does not
have an impact on the acute phase of the damage. Nevertheless, modulation of adaptive immunity exerts a remarkable protective
effect on the ischemic brain and offers the prospect of new stroke therapies. As immunomodulation is not devoid of deleterious
side effects, a better understanding of the reciprocal interaction between the immune system and the ischemic brain is essential
to harness the full therapeutic potential of the immunology of stroke.
Inflammation affects the brain after stroke, and cells of the immune cytotoxic response against newly exposed brain antigens and their role
system, such as neutrophils and macrophages, have traditionally been in the acute and chronic phase of the injury. Finally, we will evaluate the
used by neuropathologists and forensic pathologists to determine the therapeutic opportunities afforded by modulation of the immune system
approximate age of cerebrovascular lesions1. Although inflammation and their potential pitfalls.
was commonly thought to be merely a reaction to tissue damage, it has
been increasingly recognized as a key contributor to the pathophysi- Inflammatory signaling in the early post-ischemic period
ology of cerebrovascular diseases, especially stroke caused by arterial Post-ischemic inflammation is characterized by an orderly sequence of
occlusion or ischemic stroke2. Recent evidence suggests that elements events involving the brain, its vessels, the circulating blood and lymphoid
of the immune system are intimately involved in all stages of ischemic organs. Inflammation is an integral part of the cascade of events triggered
cascade (Box 1), from the acute intravascular events triggered by the by ischemia and reperfusion (Box 1). The inflammatory process begins
interruption of the blood supply to the parenchymal processes leading in the intravascular compartment immediately after arterial occlusion,
to brain damage and the ensuing tissue repair. In turn, the ischemic when the ensuing hypoxia, changes in shear stress and production of
brain, through the autonomic nervous system, exerts a potent suppres- reactive oxygen species (ROS) trigger the coagulation cascade, and lead
sive effect on lymphoid organs that promotes intercurrent infections, to activation of complement, platelet and endothelial cells6–9(Fig. 1).
a major determinant of stroke morbidity and mortality3,4. Therefore, The resulting intravascular formation of fibrin traps platelets and leu-
the immune system is closely involved on determining the fate of the kocytes, leading to microvascular occlusions10,11. Within minutes after
ischemic brain and the survival of people after stroke. In multiple scle- ischemia, the adhesion molecule P-selectin is translocated to the surface
rosis, the classical inflammatory disease of the central nervous system membrane of platelets and endothelial cells12, and proinflammatory sig-
(CNS), elements of innate and adaptive immunity are engaged in the nals are rapidly generated (Table 1). Oxidative stress in endothelial cells
post-ischemic brain5. Thus, molecular cues generated by cerebral isch- reduces the bioavailability of nitric oxide (NO), which is a potent vaso-
emia activate components of innate immunity, promote inflammatory dilator and an inhibitor of platelet aggregation and leukocyte adhesion12.
signaling and contribute to tissue damage. At the same time, these Loss of the beneficial effects of NO exacerbates intravascular plugging
processes stimulate a potentially damaging adaptive immune response and aggravates the ischemic insult by reducing blood flow to the ische-
directed at antigens previously sequestered behind the blood-brain bar- mic territory13,14. Furthermore, oxidative stress leads to constriction of
rier (BBB). These recent developments warrant a reevaluation of the pericytes, contractile cells that replace myocytes in capillaries, producing
contribution of inflammation and immunity to stroke pathophysiol- more microvascular occlusions15. Oxidative stress and inflammatory
ogy. This review will discuss the involvement of innate and adaptive mediators also alter the permeability of the BBB, which increases the
immunity in ischemic brain injury and their impact on tissue damage number of pinocytotic vesicles in the cytoplasm of endothelial cells,
and repair. Furthermore, we will examine the evidence for an adaptive enhancing transendothelial transport16. Proteases are expressed in vas-
cular cells and released by leukocytes, whereas junctional proteins that
Division of Neurobiology, Department of Neurology and Neuroscience, Weill seal adjacent endothelial cells are downregulated, facilitating extravasa-
Cornell Medical College, New York, New York, USA. tion of proteins and cells through the paracellular route (Fig. 1)16. In
Correspondence should be addressed to C.I. (coi2001@med.cornell.edu). the perivascular space, ischemia and reperfusion activate perivascular
796 volume 17 | number 7 | july 2011 nature medicine

review
Platelet
Intravascular
P-selectin activation C3a
Ischemia-- PSGL-1 Mac-1
reperfusion
n Leukocyte
y AA Protease
Prote ase
Hypoxia, ROS,
OS, release
relea
ase
shear stresss IL-1a LFA-1
Vascular wall
EC Tight junction IICAM-1 NO
Open BBB ROS
RO
O
Myocyte
Perivascular
P2X7 Histamine
space
proteases
TNF IL-1b TNF CD8888
C5a
Macrophage Mast cell Glu Astrocyte
Brain parenchyma
CX3CL1
Glu
CD200 CX3CR1
GluR1
Neuron CD200R ATP
Katie Vicari
P2X7
P2Y2 TNF
ATP IL-1b
Microglia ROS
Figure 1 Early vascular, perivascular and parenchymal events triggered by ischemia and reperfusion. Hypoxia, ROS and changes in shear stress initiate the
cellular events induced by ischemia and reperfusion. In the vessels lumen, ischemia and reperfusion lead to blood clotting, platelet aggregation and cytokine
(IL-1a) release. Translocation of P-selectin on the surface of platelets and endothelial cells leads to platelet-leukocyte aggregation. Complement is activated,
and arachidonic acid metabolites (AA) are released. In the vascular wall, upregulation of E- and P-selectin on endothelial cells provides a platform for low
affinity leukocyte binding through interaction with glycoproteins expressed on leukocytes, for example, P-selectin glycoprotein ligand-1. Firm adhesion
is obtained after endothelial expression of ICAM-1 interacting with leukocyte b2 integrins (LFA-1 and Mac-1). Loss of NO promotes vasoconstriction and
enhances leukocyte and platelet aggregation. MMP activation could lead to BBB breakdown and matrix proteolysis, facilitating leukocyte extravasation. In
the perivascular space, chemotactic complement subunits (C5a) acting on mast cell complement receptors (CD88) leads to degranulation and release of
histamine and proteases, contributing to BBB leakiness. Cytokines (TNF, IL-1b) are produced by mast cells and perivascular macrophages, providing further
signals to guide leukocyte migration across the vessel wall. In the brain parenchyma, injured cells release purines (ATP), which act as early proinflammatory
signals leading to production of cytokines and chemokines. Disruption of neuronal-microglial interaction (CX3CL1, CD200) and increases in extracellular
glutamate (Glu) acting on microglial GluR1 metabotropic receptor27 also contribute to the proinflammatory milieu.
macrophages and mast cells. Mast cell degranulation releases vasoac- (Fig. 1), activation of these receptors downregulates microglial cytokine,
tive mediators, such as histamine, proteases and tumor necrosis factor ROS and NO production27 and suppresses the secretory response in
(TNF), whereas activated macrophages release proinflammatory cyto- mast cells28,29. Therefore, ATP represents an early neuronal danger sig-
kines17–20 (Box 2) (Fig. 1). These proinflammatory mediators contribute nal, promoting the inflammatory response of resident immune cells,
to the endothelial expression of adhesion molecules and to the BBB whereas neurotransmitter release may oppose these changes and coun-
damage that promotes the infiltration of leukocytes (neutrophils, lym- teract inflammation.
phocytes and monocytes)19. Cell death and pattern recognition receptors in the post-ischemic
brain. A different signaling landscape emerges after cells begin to die.
Ischemic cell death sets the stage for innate and adaptive A wide variety of molecular signals is released from the intracellular
immunity compartment or is generated by the action of lytic enzymes escaped
As the ischemic cascade progresses (Box 1), cell death leads to a new from dead cells on matrix proteins (Fig. 2). These so-called danger-
phase of the inflammatory response (Fig. 2). Dying and dead cells release associated molecular pattern molecules (DAMPs) activate pattern
‘danger signals’ that activate the immune system21. Some of these signals, recognition receptors, including Toll-like receptors (TLRs) and scav-
such as the nucleotides ATP and UTP, are released by cells under stress enger receptors, which are widely expressed on microglia, perivascular
when the cell membrane is still intact and set the stage for the subsequent macrophages and brain endothelial cells30. DAMPs and purines act
immune response22. in concert to induce the expression of proinflammatory molecules in
ATP and neurotransmitters. Extracellular ATP abundance increases infiltrating leukocytes (Table 1) and to prime dendritic cells (DCs) for
within minutes after ischemia as a result of neuronal and glial depolar- antigen presentation (Boxes 2 and 3) (Fig. 2). Considering the high
ization or escape through damaged plasma membranes23–25. ATP is also vascular density of the brain, inflammatory mediators released from
released by vascular cells and blood cells and may promote intravascular parenchymal cells are likely to feed back on the vascular and perivas-
coagulation and platelet aggregation26. High parenchymal ATP amounts cular compartments to reinforce and amplify the expression of cytok-
activate P2X7 receptors in microglia, leading to release of proinflam- ines, chemokines and adhesion molecules that drive the infiltration of
matory mediators (Fig. 2). Activated microglia develop many charac- blood-borne cells into the ischemic tissue. After neuronal death, loss of
teristics of macrophages, including ameboid morphology, migratory cell-to-cell interaction between neurons and microglia, which are kept
capacity, phagocytosis and major histocompatibility complex (MHC) quiescent in the normal state by contact with neurons, also promotes
class II–restricted antigen presentation (Box 3). At the same time, neuro- inflammatory signaling (Fig. 1). For example, CD200, a surface protein
transmitters release after ischemia and reperfusion may counteract the expressed in neurons, interacts with its receptor CD200R on microglia,
emerging inflammatory response. Microglia express a wide variety enforcing a resting phenotype31. Disruption of this interaction due to
of neurotransmitter receptors, including AMPA, kainate, adrenergic, post-ischemic loss of CD200 (ref. 32) may promote microglial activa-
GABAB opioid and cannabinoid receptors27. With some exceptions27 tion (Fig. 1). Similarly, CX3CL1 (fractalkine), a cell surface–bound
nature medicine volume 17 | number 7 | july 2011 797

review
Table 1 Mediators of post-ischemic inflammation and their producing cells

Initiation Amplification Resolution
Nontranscriptional (cell type) Transcriptional (cell type) Transcriptional (cell type)
Adhesion molecules Adhesion molecules Growth factors
P-selectin (EC, PLT) ICAM-1, VCAM-1, P-selectin, E-selectin, Mac-1, VLA-1, BDNF, EPO, FGF, G-CSF, GDNF, HB-EGF, IGF-1,
(EC, Leuk, PVM, MG, AG) NGF, VEGF (MG, AG, PVM, Macr, EC, Neu)
Cytokines Cytokines Cytokines
IL-1b (MG, PVM, MC) IL-1, IL-6, IL-10, IL-17, IL-20, TNF (EC, PVM, MG, AG, TGF-b, IL-10, IL-17, IL-23, (T cells, MG, Macr, AG)
IL-1a (PLT) Neu)
TNF (MC)
Chemokines Chemokines
CCL5 (RANTES), CXCL4, CXCL7 (PLT) CCL2 (MCP-1), CCL3 (MIP-1a), CCL5 (RANTES), CXCL2/3
CX3CL1 (Fractalkine) (Neu) (MIP2), CXCL8 (IL-8) (EC, PVM, MG, AG, Neu)
Proteases Proteases Proteases
Elastase, MMP-8, MMP-9, MT6-MMP (Leuk) MMP2, MMP9 (EC, Leuk) MMP-9 (AG, Neu)
Clotting factors (Circ) Complement (Circ, EC, AG, Neu) Complement (Circ, EC, AG, Neu)
Complement (Circ, EC, AG, Neu)
Small molecules Other Small molecules
Prostanoids, leukotrienes iNOS (MG, Leuk, EC) Cyclopentenones prostaglandins
(EC,PLT,MG, Neu) COX-2 (Neu, MG, Leuk, EC) Lipoxins
ATP (Circ, Neu) LOX (Neu, Leuk) Docosanoids (resolvins, protectins)

Radicals (EC, PLT, Leuk, PVM, MG, Neu) PTGES (Neu, MG, Leuk, EC)
NADPH oxidase (MG, Leuk)
AG, astroglia; Circ, plasma; EC, endothelial cells; Leuk, leukocytes; Macr, macrophages; MC, mast cells; MG, microglia; Neu, neurons; PLT, platelets; PVM, perivascu-
lar macrophages. BDNF, brain-derived growth factor; COX-2, cyclooxygenase-2; EPO, erythropoietin; FGF, fibroblast growth factor; G-CSF, granulocyte colony–stimulat-
ing factor; GDNF, glial cell–derived neurotrophic factor; HB-EGF, heparin-binding epidermal growth factor-like growth factor; LOX, lipoxygenase; Mac-1, macrophage-1
antigen; MIP, macrophage inflammatory protein; NGF, nerve growth factor; PTGES, prostaglandin E2 synthase-1; RANTES, regulated upon activation, normally
T-expressed, and presumably secreted; VCAM-1, vascular adhesion molecule 1; VLA-1, very late activation antigen-1 (see Supplementary Table 1 for references).
chemokine constitutively expressed by neurons, suppresses microglial tion5. Growing evidence also indicates adaptive immunity in stroke.
activation through its microglial receptor CX3CR1. Thus, after neu- Stroke and adaptive immunity. Antibodies against CNS antigens
ronal injury, loss of CX3CL1 results in enhanced microglial activation develop after ischemic stroke, suggesting a humoral immune response
in several inflammatory disease models33. In addition, increasing con- to the injury, and circulating T cells become sensitized against CNS
centrations of extracellular glutamate activate metabotropic glutamate antigens, such as myelin basic protein (MBP) and related peptides
receptors on microglia, leading to a proinflammatory phenotype34 (Table 2). Antigen-presenting cell (APC) numbers are reduced in the
(Fig. 1). Therefore, as neuronal death develops in the ischemic core periphery and increased in the ischemic brain both in rodent and human
and spreads to the penumbra, the loss of the immunosuppressive effect stroke35–38. The accumulation of APCs coincides with the peak of lym-
afforded by neurotransmitter release and neuron-microglia interaction phocytic infiltration and is associated with expression of MHC class II
may also foster post-ischemic inflammation. molecules and the co-stimulatory molecule CD8035,37,38, findings sug-
Collectively, these observations suggest that the inflammatory gestive of antigen presentation (Box 3). Support for involvement of adap-
response after ischemia and reperfusion starts at the vascular level, tive immunity also comes from studies on the role of lymphocytes in
driven by nontranscriptional events triggered by hypoxia, shear stress rodent models of focal cerebral ischemia. Ischemia leads to infiltration
and ROS production. As ischemia damages the brain tissue, danger of the major lymphocytes subtypes into the ischemic brain37 (Box 3),
signals are released first from cells under stress and then from necrotic and increasing evidence suggests that they contribute to ischemic
cells. Concomitant with the loss of immunosuppressive mechanisms, injury (Table 2 and Fig. 3). In fact, lymphocyte-deficient mice are pro-
these signals activate purinergic receptors and pattern recognition tected from ischemic damage39,40. The protection has been attributed
receptors, which induce an inflammatory response in resident brain to T cells, because B cell–deficient mice or lymphocyte-deficient mice
cells and infiltrating leukocytes, resulting in inflammation-induced cell reconstituted with B cells are still protected from injury (Table 2). gdT
death (Box 4). cells also have been shown to contribute to the injury by releasing the
proinflammatory cytokine IL-17 (ref. 41) (Fig. 3). In contrast, T regu-
Does adaptive immunity contribute to ischemic brain injury? latory (Treg) cells are protective in the late stage of cerebral ischemia,
Danger signals released from damaged cells also promote the presen- an effect evident only if the injury is small42,43. Additional evidence in
tation of tissue antigens that were previously hidden by the BBB or favor of the involvement of cell-based adaptive mechanisms in stroke
that develop as a result of the breakdown of cell membranes21 (Fig. 2). damage was provided by studies in which animals were tolerized against
Antigen presentation leads to the development of cellular and humoral myelin-derived peptides (Table 2). Repeated mucosal administration of
immunity directed against the antigens (Box 3). This adaptive immune myelin antigens (tolerization) before arterial occlusion protects rodents
response has the potential of inducing autoimmunity against the organ from ischemic brain injury44. Although tolerization is antigen specific,
in which the cell death occurred, as described in the heart (Dressler’s its beneficial effects are not restricted to immune responses directed
syndrome), eye (sympathetic ophthalmia) and pancreas (diabetes)21. at the inducing antigen, but are instead more widespread, a phenom-
Furthermore, the damaging effect of adaptive immunity is well estab- enon termed bystander suppression44. The protection can be induced
lished in multiple sclerosis and in models of autoimmune demyelina- in naive mice by adoptive transfer of splenocytes or CD4+ T cells from

review
Figure 2 Cell death and activation of pattern

Proteases,
recognition receptors set the stage adaptive immunity. hydrolases
Release of nucleotides (ATP, UTP) from injured cells, Injured
including neurons, activates purinergic receptors on neuron
microglia and macrophages and leads to production
of proinflammatory cytokines25. Although most of Matrix Tissue
these cytokines are transcriptionally induced, IL-1b degradation damage
and IL-18 are processed from their propeptides ECM
by the activity of interleukin-1–converting enzyme
HMGB1
(ICE; caspase 1). ICE is embedded in a multiprotein DAMPs
HSP60
complex (NLRP3, or inflammasome) and is activated ROS
Ab Leukocyte
by microglial P2X7 receptors108. Ischemic cell death infiltration
ATP TLR4
leads to the formation of DAMPs, which activate UTP
TLRs, especially TLR2 and TLR4 (ref. 21). DAMPs TLR2 T cell
released by ischemia include high-mobility group Pro–IL-1b IL-1b
protein B1, an intracellular DNA binding protein CD36
IL-18
released after cellular injury, heat shock protein 60 P2X7 NF-kB IL-6
30
and b-amyloid (Ab), among others . TLRs, in concert DC
TNF
with scavenger receptors such as CD36, upregulate Caspase-1 Adaptive
proinflammatory gene expression through the immunity
Microglia/
transcription factor nuclear factor-kB30,109. DAMPs macrophage NLRP3
are also derived from matrix breakdown by lytic
enzymes released from dead cells and by the action of
ROS on lipids. The cytokine production and complement activation resulting from these events leads to increased leukocyte infiltration and enhances tissue
damage, which, in turn, produces more DAMPs. Antigens unveiled by tissue damage are presented to T cells, setting the stage for adaptive immunity.
tolerized animals45,46, suggesting the involvement of cellular immune result from suppression of autoreactive T cells targeted against myelin49.
mechanisms. Examination of T cell function indicated that activation Although RTLs may not bind T cells—but rather APC and platelets50—
of tolerized T cells by the antigen unveiled by the stroke induces a TH2 the findings suggest a role of cellular immunity in the mechanisms of
cytokine response (Box 3)45,47,48. The effect has been attributed to IL-4 ischemic brain injury.
and IL-10 production, which favors the formation of transforming Despite the evidence supporting an autoimmune response against
growth factor-b (TGF-b)-secreting Treg cells45,46,48. Other studies have the post-ischemic brain, there are inconsistencies with the hypothesis
found that administration of recombinant T cell receptor ligand (RTL), that classical adaptive immunity contributes ischemic brain injury. The
consisting of a1 and b1 domains of MHC class II complex bound to a temporal profile of the involvement T cells in brain damage is not con-
myelin peptide antigen (myelin oligodendrocyte glycoprotein (MOG)- sistent with established concepts of adaptive immunity51 (Fig. 3). Thus,
35–55), reduces stroke volume in focal ischemia49. The protective effect the protective effect observed in lymphocyte-deficient mice or afforded
is associated with reduction of infiltrating inflammatory cells and may by blocking postischemic trafficking of T cells into the ischemic brain
BOX 1 From ischemia to infarction: the ischemic cascade

Brain function depends on the continuous delivery of oxygen and for a prolonged period of time after the insult, but the neurons
glucose through blood flow, and interruption of the cerebral blood are stressed and critically vulnerable to pathogenic events that
supply leads to irretrievable brain damage2. Ischemic damage may tip their fragile metabolic balance2. Excessive extracellular
results from a cascade of cellular and molecular events triggered accumulation of glutamate is a major factor contributing to the
by sudden lack of blood flow and subsequent reperfusion of demise of the ischemic penumbra. The resulting overactivation of
the ischemic territory. Neurons are more vulnerable than glia the NMDA subtype of glutamate receptors leads to cytoplasmic
and vascular cells and become quickly dysfunctional or die accumulation or Ca2+, which activates Ca2+-dependent enzymes,
when exposed to hypoxia-ischemia123. In ischemia produced by including the proteases calpain and caspase, and enzymes
occlusion of the middle cerebral artery, the most common type producing nitric oxide, free radicals and arachidonic acid
of stroke, the damage is more rapid and severe in the center of metabolites123. These events lead to necrosis or programmed cell
the ischemic territory (ischemic core), where flow is lowest2. death depending on the intensity of the insult and the metabolic
At the periphery of the ischemic region, the so-called ischemic state of the neurons2,123. Injured and dying cells have a key role in
penumbra, neuronal damage develops more slowly because blood post-ischemic inflammation because they release danger signals
flow arising from adjacent vascular territories (collateral flow) that activate the immune system.
keeps cerebral perfusion above the threshold for immediate cell The mechanisms of ischemic stroke have been studied in in
death2. In the ischemic core, the major mechanism of cell death vitro and in vivo models of cerebral ischemia2,123; however, these
is energy failure—without oxygen and glucose, neurons cannot models do not recapitulate all the features of human stroke and
generate the ATP needed to fuel the ionic pumps that maintain may introduce important confounders, such as anesthesia and
the ionic gradient across the neuronal membrane, mainly the Na+- surgical trauma. Furthermore, differences in vascularization and
K+ ATPase123. Consequently, massive Na+ and Ca2+ cytoplasmic immune responses in the human brain (Box 2) may alter the
accumulation leads to swelling and degeneration of the organelles, initiation and evolution of the tissue damage. Nevertheless, the core
loss of membrane integrity and dissolution of the cell (necrotic features of stroke pathophysiology are comparable between animals
cell death)123. In the ischemic penumbra, the flow reduction is and humans, and animal models of cerebral ischemia remain a
not sufficient to cause energy failure, and neurons remain viable mainstay of preclinical stroke research124.

review
Table 2 Selected evidence for and against the involvement of adaptive immunity in ischemic brain injury
In favor of adaptive immunity causing tissue damage
Evidence Findings References
CNS antigens and associated humoral response are present after MBP, NSE, S100b, GFAP, NMDA receptor, neurofilament 117–119
stroke
T cell response to CNS antigens after stroke Lymphocyte sensitization to CNS antigens 120
APC increase in the human and rodent brain after stroke DC and macrophages found in perivascular space and brain parenchyma after stroke 35–38
gdT cells and Treg cells are involved in experimental stroke gdT cells contribute to brain damage through IL-17; Treg cells are protective in the 41,42
late phase of cerebral ischemia
T cells sensitized against CNS antigens mediate damage in stroke RTL targeted to myelin-specific T cells reduces ischemic brain injury 49
Tolerization to CNS antigens is protective in experimental stroke Mucosal administration of MBP or MOG reduces damage in focal ischemia 44
Against adaptive immunity causing damage
Evidence Findings References
Temporal dissociation between adaptive response and tissue T cell–mediated damage occurs early (<24 h) after stroke, not consistent with anti- 39,52
damage gen presentation and clonal expansion
T cell–mediated ischemic damage is antigen independent T cells reactive against CNS or non-CNS antigens are equally damaging 40
Absence of co-stimulatory molecules necessary for antigen pre- Mice lacking CD28 or B7 are not protected from focal ischemia 40
sentation does not affect stroke outcome
Unlike other models of autoimmunity, both CD4+ and CD8+ T CD4- and CD8-null mice are equally protected 41,52
cells are involved in the injury
CD, cluster of differentiation; GFAP, glial fibrillary acidic protein; MBP, myelin basic protein; NSE, neuron specific enolase.
occurs 24–48 h after ischemia40, whereas adaptive responses require an thrombotic actions leading to microvascular occlusions52. These effects
interval of 7–10 d from antigen presentation to the clonal expansion of would be deleterious by preventing reperfusion and by compromising
autoreactive T cells and immune attack on the target organ51 (Box 3). collateral flow after ischemia and reperfusion. But lack of lymphocytes
Furthermore, reconstitution of lymphocyte-deficient mice with T cells does not improve post-ischemic cerebral blood flow at least in the acute
targeting non-CNS antigens worsens ischemic damage, and mice lacking phase53, nor does it suppress thrombus formation40. Therefore, effects
co-stimulatory molecules essential for antigen-specific T cell response of lymphocytes altering microvascular perfusion or patency seem
are not protected from ischemia40. It is also surprising that, unlike auto- unlikely. Another possibility is that natural killer T (NKT) or gdT cells,
immune responses in other organs where there is a prevalence for either T cells that have a simplified T cell receptor (TCR) and may not require
T helper or T effector cell participation, both CD4+ and CD8+ T cells antigen processing and MHC presentation, as well as NK cells (Box 3),
are involved in ischemic injury52. Collectively, these observations argue are responsible for these early cytotoxic effects of lymphocytes. In sup-
against an autoimmune attack on the brain resulting from presentation port of this hypothesis, NKT cells are not present in recombination-
of CNS antigen released by the stroke. activating gene 1 (Rag1)-/- mice and severe combined immunodeficient
The lymphocyte puzzle. If lymphocytes do not mediate an autoim- mice54, and they could contribute to explain the early neuroprotection
mune attack on the brain, how do they contribute to the early phase of observed in these models of lymphocyte deficiency39,40. However, CD1-
ischemic brain injury? One possibility is that these cells participate in deficient mice lack NKT cells and are not protected from ischemic
the cerebrovascular dysfunction occurring after ischemia or have pro- injury 24 h after middle cerebral artery occlusion40, suggesting that
NKT cells may not be involved in the early phase of the injury. gdT
Acute phase of ischemia Delayed phase of ischemia cells have been implicated in ischemic brain injury, but their involve-
ment seems restricted to the late phase of cerebral ischemia (4 d)40,41.
Unprimed γδ CD4+ Helper CD8+
function Considering the limited number of studies available, the involvement
T cell T cell T cell T cell
of NK, NKT and gdT cells, lymphocyte subtypes that act in a fashion
ROS?
IFN-γ? IL-17 akin to innate immunity, needs further exploration.
Detrimental
IL-12 MHC MHC

IL-23 Figure 3 Deleterious and beneficial roles of T cells in stroke. In the acute
class II class I
phase of cerebral ischemia, unprimed T cells contribute to tissue damage
in an antigen-independent manner (innate immunity), possibly through
IFN-g110 and ROS111 (top left). gdT cells, activated by IL-23 released from
APC EC, neuron, microglia and macrophages, produce the cytotoxic cytokine IL-17 and
Microglia/ astrocyte, APC contribute to acute ischemic brain injury41. However, T cells can also be
macrophage
protective. TGF-b produced by neurons, glia, or microglia and macrophages
Treg cell
promotes the development of Treg cells secreting the protective cytokine
TGF-β IL-10 and inhibits TH1 and TH2 responses. Treg cells are protective in
Protective
Neuron TH2 cell IL-10

models of cerebral ischemia42. Induction of mucosal tolerance with CNS
TGF-β
IL-10 antigens produces an adaptive response, which leads to the establishment
Astrocyte of autoreactive TH2 cells producing IL-10 (ref. 48) and Treg cells producing
Tolerization IL-10 and TGF-b107 is highly protective in experimental stroke (bottom
right). Although there is no evidence that adaptive immunity contributes to
acute ischemic brain injury, weeks and months after stroke, autoreactive
CD4+ and CD8+ T cells targeting CNS antigens could develop (top right).
Katie Vicari
CNS antigens
The resulting cell death could play a part in the delayed brain damage and
Innate Adaptive atrophy that occur after stroke83.

review
BOX 2 Cells of the innate immune system

Cerebral ischemia engages both innate and adaptive immunity, the Blood monocytes are direct precursors of tissue macrophages.
two main braches of the vertebrate immune system51. The innate At least two different monocyte populations have been
system is germline encoded and rapidly activated, and it relies on described in humans and mice according to their surface
low-affinity receptors to gain wide-ranging target recognition. The markers and function. ‘Classical’ monocytes produce the anti-
adaptive system is based on high-affinity receptors, including inflammatory cytokine IL-10 when challenged with LPS, whereas
T cell receptors and immunoglobulins, which are randomly ‘proinflammatory’ monocytes produce TNF. After cerebral
generated by somatic mutations. In contrast to the innate system, ischemia, inflammatory monocytes are rapidly recruited to the
adaptive immunity needs antigen-driven clonal cell expansion, a site of injury, where they give raise to macrophages and DCs 35.
process that requires several days, and retains a memory of this
antigen exposure51. Although specific cell types are predominantly Dendritic cells are specialized APCs that constitute the main
associated with one of the two branches, there is considerable interface between innate and adaptive immunity (Box 3). In the
overlap between the role of these cells in innate and adaptive normal brain, DCs are associated with meninges, choroid plexus
immunity. Here we describe cells predominantly associated with and the cerebrospinal fluid. Cells expressing DC markers (CD11c,
innate immunity. Lymphocytes are described in Box 3. MHC class II) appear in the brain parenchyma after focal ischemia
and originate from resident and blood-borne cells35.
Microglia derive from the hematopoietic system and constitute the
innate immune cells of the CNS125. Resting microglia survey the Neutrophils are secretory and phagocytic cells of the innate
brain parenchyma through continuous extension and retraction of immune system and carry different types of cytoplasmic granules
their processes. Microglia contribute to post-ischemic inflammation and secretory vesicles. Major proinflammatory molecules
by producing TNF, IL-1b, ROS and other proinflammatory mediators stored in granules and vesicles include iNOS, NADPH oxidase,
(Table 1 and Fig. 1). However, they also contribute to the resolution myeloperoxidase, MMP-8, MMP-9, elastase and cathepsins.
of inflammation and tissue repair by producing IL-10 and TGF-b, as After cerebral ischemia, neutrophils adhere to the cerebral
well as several growth factors, including IGF-1 (Table 1 and Fig. 4). endothelium and transmigrate into the tissue12. Vesicle and
granule exocytosis is induced after receptor engagement,
Perivascular macrophages are confined to the space between such as binding to E-selectin on endothelial cells and IL-8
the vascular basement membrane and the brain surface (glia stimulation129.
limitans) and, unlike microglia, are continuously replenished by
hematogenous precursors126. Macrophages can be classified Is the immune system comparable in rodents and humans?
into two groups: M1 macrophages that produce proinflammatory Circulating neutrophils predominate in humans (50–70%),
cytokines (IL-1b, IL-12, IL-23 and TNF), chemokines, ROS whereas lymphocytes predominate in rodents (75–90%) 130.
and NO, promoting a TH1 immune response (Box 3), and M2 Several immune-related molecules, such as iNOS, P2X7,
macrophages that produce anti-inflammatory cytokines (IL-10 and TLR2, antigen-presenting proteins, co-stimulatory molecules,
TGF-b), IL-1ra and arginase127. After cerebral ischemia, cytokines immunoglobulins and chemokines, are differentially expressed in
produced by perivascular macrophages are thought to drive the mice and humans or present in one species and not the other 130.
infiltration of inflammatory cells19. Human endothelial cells can present antigens to resting CD4 +
and CD8+ T cells, whereas mouse endothelial cells can only
Mast cells are found in meninges and cerebral blood vessels. Mast activate CD8+ T cells131. Consequently, the immune responses
cells granules store vasoactive substances (histamine), cytokines initiated by vascular pathologies may differ quantitatively and
(TNF), anticoagulants (heparin) and proteases (tryptase, chymase, qualitatively between humans and mice. The impact of these
MMP2 and MMP9)17,18. In addition, mast cells are capable of differences needs to be considered when translating findings
phagocytosis and antigen presentation and can modulate the obtained from rodent models of cerebral ischemia to human
adaptive immune response128. stroke.
Collectively, these studies suggest that, although an antigen-specific reorganization of the injured brain. The factors governing resolution
immune response may develop after stroke, evidence showing that of inflammation and the reestablishment of tissue homeostasis are still
autoreactive T cells can attack the brain tissue after CNS antigens poorly understood, particularly in brain. Increasing evidence suggests
against which they were sensitized are exposed by ischemic damage is that resolution of inflammation is not a passive process due to exhaus-
lacking. Lymphocytes have a role in the development and progression tion of the signaling; instead, it is orchestrated by the interplay of a large
of the injury, but how they exert their powerful effect does not conform number of mediators that actively suppress the inflammatory response55.
to the tenets of classical autoimmunity. The role of NK, NKT and gdT Major steps in the process include removal of dead cells, development
cells, which could contribute to the acute phase of the injury, needs of an anti-inflammatory milieu and generation of prosurvival factors
further exploration. Similarly, considering the evidence for humoral fostering tissue reconstruction and repair55,56.
immune responses in stroke (Table 2), the contribution of B cells to Clearing dead cells. Microglia and infiltrating macrophages consti-
the damage needs a more in-depth assessment. tute the predominant phagocytes removing dead cells and tissue debris
after stroke57,58, a process orchestrated by ‘find me’ and ‘eat me’ sig-
Resolution of inflammation and tissue repair nals. Find-me signals, including purines released from injured cells and
Post-ischemic inflammation is a self-limiting process that eventually chemokines, attract microglia and macrophages to the site of injury59,60
subsides and prepares the terrain for the structural and functional (Fig. 4). These phagocytic cells are then presented with eat-me signals

review
Post-ischemic
Clearing dead cells inflammation resolution Brain repair
VEGF
Antigen
presentation Neuron
‘Find me’
Dying UTP, ATP, MMPs
neuron P2Y2
chemokines
DC
PtdSer Blood
BDNF BDNF vessel
Neutrophil G-CSF VEGF
IgG TIM4 ‘Eat me’ NGF

P2Y6 UDP FGF
FcR
HB-EGF
Treg cell ICAM-1
IL-10
TGF-b
Resolvins EC
Microglia/ Protectins Astrocyte/ IGF-1
Microglia/
macrophage Lipoxins oligo GDNF
macrophage
Proinflammatory
Katie Vicari
cytokines
Neuroprotective IL-1, TNF
Figure 4 Resolution of inflammation and tissue repair. Clearing of dead cells and suppression of inflammation are key events in brain repair. Find-me signals
(UTP, ATP) attract microglia and macrophages through P2Y2 receptors. Eat-me signals include UDP, which acts on P2Y6 receptors to stimulate microglial
phagocytosis112, and phosphatidylserine (PtdSer), which is translocated to the outer leaflet of the plasma membrane of apoptotic cells 112. PtdSer-binding
proteins involved in the clearance of dead cells include milk fat globule epidermal growth factor 8 protein on microglia 113 and T cell immunoglobulin and
mucin domain-containing molecule 4 (TIM4) on macrophages112. Immunoglobulins directed against CNS antigens, which appear after stroke (Table 2), may
also promote phagocytosis by engaging Fc receptors on phagocytic cells. Phagocytosis promotes secretion of IL-10 and TGF-b 56, which, in turn, suppress
antigen presentation, promote Treg formation, inhibit expression of adhesion molecules in endothelial cells and production of proinflammatory cytokines 61.
TGF-b and IL-10 are also neuroprotective114,115 and may facilitate brain repair processes. In addition, lipoxins, resolvins and protectins, metabolites of
arachidonic acid and omega-3 fatty acids that play an active part in the resolution of inflammation in other organs 55, could also contribute to suppress post-
ischemic inflammation. Growth factors and MMPs produced by endothelial cells, neurons, astrocytes, oligodendrocytes and microglia are key molecules
driving tissue reorganization and repair63,116.
associated with dying or dead cells (Fig. 4). recovery has also been highlighted by studies in which the transcriptome
TGF-β, IL-10 and the anti-inflammatory milieu. TGF-b and IL-10 of sprouting neurons indicated involvement of MHC I class molecules
are pleiotropic immunoregulatory cytokines that have a crucial role in and complement subunits66.
the development of the anti-inflammatory milieu associated with tis- This evidence indicates that cells of the immune system have a fun-
sue repair (Fig. 4). The production of these cytokines is promoted by damental role in all the phases of post-ischemic brain recovery. But the
phagocytosis and occurs in concert with the removal of dead cells56. limited data available provide only a glimpse into the complex sequence
TGF-b, which is upregulated after ischemia primarily in microglia and of events that reestablish the structural and functional homeostasis of
macrophages, has neuroprotective properties and profound effects on the brain after stroke. Additional studies on recently identified media-
immune cells. Although TGF-b is well known for its proinflammatory tors instrumental to inflammation resolution and tissue repair, such as
effects, it can also suppress inflammation by inhibiting T helper type lipoxins, resolvins, protectins, progranulins and cyclopentenone prosta-
1 (TH1) and TH2 responses and promoting Treg cell development61. glandins (Table 1 and Fig. 4)55,56, are needed to fully elucidate the role
Similarly, the immunoregulatory cytokine IL-10, produced by multiple of the immune system in brain repair after stroke.
cell types, including Treg cells42, has both neuroprotective and anti-
inflammatory activities (Fig. 4). Therefore, post-ischemic production of Stroke and systemic immunity
TGF-b and IL-10 can facilitate tissue repair by promoting the resolution Concomitant with the inflammatory response involving the brain,
of inflammation and exerting direct cytoprotective effects on surviving immunological changes are also observed in the blood, bone marrow,
cells in the ischemic territory. spleen and other lymphoid organs3,73. Genome profiling of peripheral
Growth factors. Post-ischemic production of growth factors helps to blood in individuals after stroke has demonstrated characteristic pat-
establish an environment that is favorable to neuronal sprouting, neu- terns of inflammatory gene expression that can help determine the cause
rogenesis, angiogenesis, gliogenesis and matrix reorganization62–64. of ischemic stroke74, reflecting the specificity of the systemic inflam-
Inflammatory cells, as well as neurons and astrocytes65,66, are capable matory response to brain injury. In rodent models, as in people with
of producing a vast array of growth factors (Table 1). For example, ischemic stroke, white blood cell count and expression of cytokines and
microglia are required for the full expression of insulin-like growth inflammatory markers are increased within hours after ischemia75–78.
factor 1 (IGF-1)67, a key factor in post-ischemic neuronal sprouting66, Such an acute-phase response is followed within 1 or 2 d by a marked
whereas reactive astrocytes are required for functional recovery after immunodepression, especially in individuals with large strokes, char-
stroke68. Vascular endothelial growth factor (VEGF), which is crucial acterized by lymphopenia, reduced functional activity of monocytes,
for post-ischemic angiogenesis, is produced by reactive astrocytes69, and upregulation of anti-inflammatory cytokines, lymphocyte apoptosis and
its action may require neutrophil matrix metalloproteinases (MMPs), splenic atrophy78,79. These immunological changes are associated with
suggesting a link between inflammatory cells and angiogenesis70. But a higher tendency to respiratory and urinary tract infections, which are
VEGF administration early after ischemia or in excessive doses may responsible for considerable morbidity and mortality in people after
enhance the damage71,72. The role of inflammatory signaling in brain stroke3,4. Infections tend to occur in patients with larger stroke and

review
BOX 3 The spectrum of lymphocyte subtypes

Lymphocytes are key cells in innate and adaptive immune and IL-6 and involves the transcription factor RORgt132. TH17 cells
responses. B cells are responsible for humoral immune responses participate in autoimmunity104 but have not been implicated in
characterized by the production of antibodies that attack and cerebral ischemic damage41. Regulatory T cells (Treg or suppressor
neutralize specific antigens51. T cells are involved in cellular T cells) either are present naturally or can develop from other TH
immunity, in which extraneous antigens are suppressed by a subtypes in the presence of TGF-b through the transcription factor
cytotoxic cellular response. T cells express the glycoprotein CD4 or FoxP3 (ref. 132). Unlike other helper T cells, Treg cells induce
CD8 on their surface, a feature that determines their function and immunosuppression by producing IL-10 and TGF-b132. Treg cells
fate. are crucial for the maintenance of the homeostasis of the immune
system by counterbalancing the destructive effects of excessive
Antigen presentation. Antigen presentation is performed by inflammation and may play a protective role in cerebral ischemia.
APCs, mainly DCs and macrophages51, and is central to adaptive
immunity. APCs patrol the environment, and when they recognize Cytotoxic T cells. In contrast to CD4+ T cells, CD8+ T cells are
a foreign antigen, they degrade it into peptides, some of which are cytotoxic. The TCR of CD8-expressing T cells binds antigen
then assembled with MHC class II molecules and displayed on the presented with MHC class I molecules, which are present in
APC surface51. The MHC class II–antigen complex is recognized every cell, and co-stimulatory molecules. After clonal expansion,
by the TCR of CD4+ T cells, and this interaction in the presence activated CD8+ T cells patrol the internal environment in search
of appropriate co-stimulatory molecules on APCs (B7-1, B7-2) of somatic cells expressing the antigens against which they were
and T cells (CD28) results in T cell activation. TCRs include either sensitized. Cytotoxic T cells kill somatic cells by permeabilizing
ab chains or gd chains, immunoglobulin-like proteins consisting the membrane with perforin and inducing apoptosis via
of variable and fixed regions51. After antigen presentation, CD4+ granzyme-induced caspase activation or the Fas ligand pathway
T cells undergo clonal expansion in lymphoid organs, a process (Box 4). Lymphocytic cells with cytotoxic function also include
promoted by autocrine production of IL-2 (ref. 51). NK cells and NKT cells. NK cells lack a TCR and, as such, do not
require antigen presentation for their activation and cytotoxicity,
Helper T cells. With notable exceptions, CD4+ T cells become which is triggered by interferons or cytokines133. NKT cells have
helper T cells that do not have cytotoxic function but act as a simplified TCR that recognizes glycolipids presented by cells
‘helpers’ by coordinating and modulating immune responses132. also expressing the MHC class I–like glycoprotein CD1 (ref. 133).
Helper T cells include effector and regulatory cells132. Depending NKT cells exert their cytotoxic effect by releasing large amounts
on the molecular signals present in their milieu, different of IFN-g, IL-2 and TNF.
subpopulations of effector helper T cells can develop to produce
a specific pattern of cytokines. TH1 effector cells secrete IFN-g γδT cells. gdT cells are a subset of effector lymphocyte with a
and TNF, and their development is promoted by IL-12 through TCR comprising gd chains and particularly enriched in mucous
the transcription factor t-bet132. TH1 cells stimulate innate and T membranes134. Like NKT cells, these cells recognize nonpeptide
cell–induced immune responses leading to cytotoxicity. TH2 cells antigens and react to danger signals produced by stressed cells134.
secrete IL-4, IL-5, IL-9, IL-10 and IL-13 and promote humoral gdT cells can exert different functions depending on the context in
immunity, mucosal immunity and responses directed against which they operate, ranging from cytolysis to antigen presentation,
extracellular pathogens132. IL-4 promotes TH2 cell development, immunoregulation and production of growth factors135. In cerebral
which is regulated by the transcription factor GATA-3 (ref. 132). ischemia, gdT cells have been implicated in both cytotoxicity and
TH17 cells secrete IL-17, and their development is driven by TGF-b protective immunomodulation.
with low CD4+ lymphocyte counts and elevated plasma levels of IL-10 survivors have dementia, often associated with brain atrophy83. The
and IL-6, reflecting immunodepression80. How these systemic immune bases for the cerebral atrophy are not entirely clear, but immunological
changes are mediated is not completely understood, but there is evidence mechanisms triggered by the stroke cannot be discounted. Pathological
that sympathetic activation and the attendant release of stress steroids studies have shown an inflammatory infiltrate that persists for years
and catecholamines are involved3,4. Thus, cortisol and catecholamines after the stroke. For example, mononuclear cells, perivascular cuffing
plasma levels are elevated in people after stroke most susceptible to infec- and macrophages can be found, respectively, in 42%, 44% and 75% of
tion81, and steroid antagonists and the b-adrenergic receptor antagonist brains with stroke in a large series1, and T cells and DCs are observed
propanolol counteract lymphocyte apoptosis and infection propensity in ‘old’ strokes38. Nevertheless, these focal inflammatory changes have
after stroke in rodent models82. not been linked to post-stroke immunosuppression or dementia, and
their pathogenic significance remains uncertain.
Bright and dark sides of post-stroke immunosuppression On the other hand, immunosuppression after stroke is deleterious
What is the biological importance of immunodepression after stroke? in that it increases the incidence of infections, a major determinant of
On the one hand, the lymphopenia and immunosuppression may limit poor neurological outcome, morbidity and mortality3,4. Acute infec-
the development of autoreactive T cells targeted to CNS antigens and tion could also negatively affect stroke outcome by upregulating co-
dampen a potential autoimmune attack on the brain3,4. The relative stimulatory molecules and promoting antigen presentation21. This
rapidity of the development of ischemic brain injury is not consistent possibility is supported by studies in which bacterial lipopolysaccha-
with the temporal profile of an adaptive response against the brain; how- ride (LPS) administered at the time of reperfusion to simulate infection
ever, it is conceivable that sensitization to CNS antigens may be involved after stroke, worsens the outcome of experimental stroke84 and increases
in the long-term outcome of the stroke (Fig. 3). About 30% of stroke post-ischemic brain atrophy assessed 1 month after stroke85,86. The

review
effect is associated with increased expression of B7.1, a co-stimulatory tory signaling, such as complement, TLR or scavenger receptors, is
molecule needed for efficient antigen presentation (Box 3), as well as T highly protective in experimental models (Supplementary Table 1).
cell sensitization against CNS antigens and a TH1 cytokine response85,86. Furthermore, minocycline, an agent with multiple neuroprotective
Therefore, immunosuppression after stroke is detrimental by increasing actions, including broad anti-inflammatory properties, has shown
the incidence of systemic infections and, possibly, by promoting antigen promise in clinical trials95 (Table 3).
presentation and autoimmunity against the brain, which may worsen Immunomodulation and T cell–based approaches. Another strat-
the long-term sequelae of the stroke. egy is to develop approaches in which the immune system is directed
to suppress the deleterious effects of inflammation while enhancing its
Bench to bedside: trials, tribulations and promising therapies protective potential.
Ischemic stroke remains an enormous therapeutic challenge. Currently, Ischemic tolerance provides an example of protective immunomodu-
thrombolysis with tissue plasminogen activator is the only effective lation. Ischemic tolerance or preconditioning is a phenomenon in which
therapy, but, owing to the narrow therapeutic window of less than 4.5 h a sublethal injurious stimulus protects an organ against a subsequent
and safety concerns, fewer than 5% of stroke patients receive this treat- lethal stimulus. For example, a short nondamaging ischemic insult to
ment87. Among the potential therapeutic approaches targeting the the brain (local preconditioning) or other organs (remote precondition-
ischemic cascade (Box 1), preclinical studies in rodent models suggest ing) protects the brain from a subsequent damaging ischemic insult2,96.
that suppression of inflammation offers unique advantages. First, these Although ischemic tolerance is known to protect the brain by simultane-
treatments have an extended therapeutic window and are effective when ously suppressing multiple pathways in the ischemic cascade2, modula-
administered up to 12–24 h after stroke88,89. Therefore, they could be tion of the post-ischemic immune response has emerged as one of its key
used in patients who fail the time window for thrombolysis. Second, effector mechanisms30,97. Similarly, administration of low doses of LPS
as suppression of inflammation is also beneficial in models of cerebral induces tolerance and protects the brain from ischemic damage26. In this
hemorrhage90, concerns about worsening brain injury in patients in case, post-ischemic TLR4 signaling is redirected toward production of
whom hemorrhagic stroke has not been excluded would be minimized interferon-b (IFN-b), which, in turn, reprograms the immune system to
and early treatment by emergency medical teams would become feasible. suppress the production of proinflammatory cytokines and the infiltra-
Finally, considering that the inflammation is particularly deleterious in tion of inflammatory cells98. But nuclear factor-kB–dependent inflam-
ischemia associated with reperfusion91,92, suppression of inflammation matory mediators, such as IL-1, TNF, inducible nitric oxide synthase
would be a fitting complement to reperfusion therapy using thrombolyt- (iNOS)-derived NO and ROS, are also required for the full expression
ics or intravascular clot removal. of the tolerance99–102, indicating that the protection does not rely just on
Although these considerations are based on animal models, which the suppression of deleterious inflammatory mediators but also on a fine
may not recapitulate in full the human disease (Box 1), inflammation balance between pro- and anti-inflammatory signaling. One of the chal-
is a crucial pathogenic component of human stroke and remains an lenges is therefore to learn how to modulate the immune system to rep-
attractive target for therapeutic intervention. licate the beneficial inflammatory milieu induced by preconditioning.
Anti-inflammatory agents. Blocking antibodies directed against Tolerization may provide the opportunity to achieve this goal. Induction
adhesion molecules (for example, intracellular adhesion molecule-1 of immune tolerance through mucosal exposure to myelin antigens or
(ICAM-1) or macrophage-1 antigen) or recombinant neutrophil inhibi- E-selectin promotes a protective TH2 response, which acts through mul-
tory factor have not been effective in clinical trials93. In the case of the tiple pathways to suppress the deleterious effects of inflammation47. As
ICAM-1 trial, the negative outcome has been attributed to deleterious tolerization must be established before injury, this approach, like precon-
immunoactivation resulting from administration of a mouse antibody ditioning, would be more appropriate for stroke prevention in high-risk
to humans, as reproduced in an experimental study in which mouse individuals than acute stroke treatment. Another strategy may be the
antibodies to rat ICAM-1 were administered to rats94. Although there administration of RTL (Table 3), given that it suppresses the infiltra-
also might be other reasons for these failures93, a probable contribut- tion of inflammatory cells and provides neuroprotection even when
ing factor is that post-ischemic inflammation acts through multiple administered after the onset of cerebral ischemia49. Similarly, adminis-
redundant pathways that cannot be effectively suppressed by blocking tration of the immunomodulatory co-polymer Poly-YE ameliorates the
a single cytokine or adhesion molecule, as attempted in these clinical neurological deficits produced by cerebral ischemia, an effect attributed
trials. Thus, neutralizing upstream mediators of the signaling cascade to increased production of growth factors and hippocampal neurogen-
or blocking multiple inflammatory pathways would be more effective esis103. The full translational potential of treatments based on immuno-
(Table 3). For example, blocking upstream components of inflamma- modulation has not been established—therapeutic window, efficacy in
Table 3 Examples of therapeutic approaches targeting multiple inflammatory pathways

Intervention Target Potential downside Development stage References
Inhibition of TLRs, complement Upstream events in inflammatory Worsening of infections after stroke Preclinical Supplementary
or scavenger receptors signaling Table 1
Minocycline Multiple, including early Generally safe, but neurotoxic in Clinical (phase 3 trial planned) 95,121
inflammatory signaling some settings
TCR ligand T cells Mechanism unknown Preclinical 49
T cell–based approaches Suppression of gdT cells Feasibility unclear Preclinical 41,42
Upregulation of Treg cells
Tolerization Promotes TH2 responses Prevention only; deleterious Preclinical 44,106
humoral response
Remote preconditioning Multiple, including inflammation Prevention, but being tested also Clinical (phase 1 trial in subarachnoid 122
in acute stroke hemorrhage completed; ischemic stroke
trials ongoing)

review
females and in aging, protection in the presence of cardiovascular risk suppression of inflammation. Furthermore, in light of stroke-induced
factors and efficacy in higher-order species need further exploration. immunosuppression, the infectious complications of therapies suppress-
Nevertheless, the powerful protective effects of immunomodulators ing inflammation also need to be taken into account (Table 3).
justify additional investigations in this direction. Therapies based on immunomodulation, in which the overall immune
The recent identification of IL-17–secreting T cells as a crucial effector response is deviated from a TH1- to a TH2-type response, also have a dark
of the tissue damage in autoimmune diseases (TH17 cells)104 and cere- side. In models of multiple sclerosis, tolerization with myelin antigens
bral ischemia (gdT cells)41 raises the possibility that counteracting IL-17 induces a protective TH2 response in the acute phase, but, in the long
could be beneficial in cerebral ischemia as it is in experimental allergic term, such TH2 response promotes B cell differentiation and leads to a
encephalomyelitis104. Boosting the protective roles of Treg cells could also humoral attack against myelin that worsens the neurological outcome106.
be beneficial42, although a destructive role of these cells has also been Worsening in the chronic phase has also been reported in tolerization
proposed105. These approaches would be desirable because they target the applied to models of cerebral ischemia107. Therefore, the delayed effects
delayed phase of the injury and are anticipated to have a particularly wide of humoral immunity could counteract the short-term benefit of suppres-
therapeutic window. Nevertheless, the role of lymphocytes in ischemic sion of cellular immunity. A more complete understanding of the immu-
injury is poorly understood, and the full implications of suppressing the nology of stroke would enable the development of targeted approaches to
action of specific T and B cell populations remain to be defined. selectively suppress the deleterious effects of inflammation.
Fighting inflammation: a double-edged sword? Immune cells
and inflammation play a key part in tissue repair and reorganization. Conclusions
These beneficial effects have to be considered in developing therapeu- Immunity and inflammation are an integral part of the pathogenic pro-
tic approaches aimed at restraining post-ischemic inflammation. The cesses triggered by ischemia and reperfusion. Inflammatory signaling
concern is that although counteracting the inflammatory response to is responsible for early molecular events triggered by the arterial occlu-
ischemic injury may ameliorate the tissue damage in the acute phase, sion and that culminate in the invasion of the brain by blood-borne
it may also compromise repair mechanisms and worsen the long-term leukocytes. Although its ultimate goal is to reestablish homeostasis,
outcome of the injury. Owing to the paucity of experimental studies in inflammation inflicts considerable damage to the metastable penum-
the recovery phase, there is no definitive experimental evidence that bral tissue. Adaptive immunity is deeply involved in the central and
anti-inflammatory treatments interfere with repair processes in the post- peripheral events triggered by cerebral ischemia, but whether a clas-
ischemic brain. However, prosurvival effects of immune cells stemming sical autoimmune response against brain antigens unveiled by tissue
from growth factor production, neurogenesis and neuroplasticity are damage contributes to the acute phase of the damage is still unknown.
well established (Table 2)105. The essential role of inflammation in tissue Lymphocytes invade the ischemic brain and contribute to tissue dam-
repair highlights the difficulties with approaches based on full-blown age, but the rapidity of their deleterious effect is not consistent with an
BOX 4 How does inflammation kill?

ROS, NO, the complement system, apoptosis-inducing receptors is indicated by the fact that deletion of endogenous complement
and the perforin pathway represent the major effectors of cell inhibitors increases brain injury, whereas their upregulation or
death in inflammation. administration is protective (Supplementary Table 1).
ROS and NO. In the setting of inflammation, O2– is produced Apoptosis inducing receptors. Fas (CD95), a member of the
mainly by NADPH oxidase, an enzyme expressed in virtually TNF receptor superfamily, is expressed on neurons and glia after
all inflammatory cells (Boxes 2 and 3). At the same time, large ischemia129, whereas its ligand FasL (CD95L) is present in
amounts of NO are produced by de novo expression of iNOS89. neurons, microglia cytotoxic T cells, gdT cells and NK cells137.
NO reacts preferentially with O2– to form the cytotoxic molecule Fas ligation results in formation of the death-inducing signaling
peroxynitrite. H2O2 is derived from O2– dismutation and gives complex and subsequent activation of caspase-8 and of the
rise to highly toxic hydroxyl radicals via the Haber-Weiss reaction, proapoptotic factor Bid. Similarly, the TNF-related apoptosis-
facilitated by the increased availability of free iron in ischemia123. inducing ligand (TRAIL) is expressed de novo after ischemia in
These toxic molecules alter cellular proteins, lipids and ribonucleic astrocytes and microglia138, and it induces apoptosis by engaging
acids, leading to cell dysfunction or death, and they have been its receptors on neurons and glia. This pathway is involved in
implicated in the tissue damage produced by post-ischemic ischemic cell death, because TRAIL inhibition or Fas mutation
inflammation. For example, suppression of NADPH oxidase or ameliorates ischemic injury138,139.
iNOS activity protects the brain in the late phase of cerebral
ischemia (Supplementary Table 1). Perforin and granzyme. This pathway is used by cytotoxic T cells,
NKT and NK cells, which release perforin and granzyme upon
The complement system. The complement system is a proteolytic molecular recognition of antigen associated with MHC class I or
cascade composed of several subunits (C1 through C9) that class I–like molecules. After engagement of accessory surface
leads to cell lysis via the formation of a pore-like structure receptors, such as ICAM-1, degranulation occurs releasing
assembled from C9 termed the membrane attack complex. the protease granzyme, perforin, which is analogous to the
Complement also enhances phagocytosis (opsonization), or acts complement subunit C9, and the proteoglycan serglycin. This
as a chemotactic-activating stimulus for inflammatory cells. After complex is internalized by the target cell, where granzyme triggers
ischemia, complement is activated, and its components are either apoptosis by activating caspase-3 and Bid. The involvement of this
upregulated in glia and neurons or enter the brain through BBB pathway in ischemic brain injury is suggested by observations that
breakdown136. The involvement of complement in ischemic damage genetic deletion of perforin is protective140.

review
adaptive immune response targeted to the brain. Remarkably, selected leukocyte surface apyrase CD39. J. Clin. Invest. 119, 1136–1149 (2009).
12. Yilmaz, G. & Granger, D.N. Leukocyte recruitment and ischemic brain injury.
lymphocyte subpopulations are protective, acting to dampen the cyto- Neuromolecular Med. 12, 193–204 (2010).
toxic effects of other inflammatory cells and promoting tissue recovery. 13. Atochin, D.N. et al. The phosphorylation state of eNOS modulates vascular reac-
The mechanistic bases for this dichotomous response of lymphocytes tivity and outcome of cerebral ischemia in vivo. J. Clin. Invest. 117, 1961–1967
(2007).
remains to be elucidated (Fig. 3). Although the participation of inflam- 14. Ishikawa, M., Zhang, J.H., Nanda, A. & Granger, D.N. Inflammatory responses to isch-
mation and immunity in tissue recovery is well established in other emia and reperfusion in the cerebral microcirculation. Front. Biosci. 9, 1339–1347
organs, very little is known about these processes in the brain. Even (2004).
15. Yemisci, M. et al. Pericyte contraction induced by oxidative-nitrative stress impairs
less clear are the long-term effects of the adaptive immune response capillary reflow despite successful opening of an occluded cerebral artery. Nat. Med.
associated with stroke and their role in the sequelae of ischemic dam- 15, 1031–1037 (2009).
16. Engelhardt, B. & Sorokin, L. The blood-brain and the blood-cerebrospinal fluid bar-
age, such as brain atrophy and dementia. Similarly, it is unclear whether riers: function and dysfunction. Semin. Immunopathol. 31, 497–511 (2009).
the immune system develops a memory of the antigen exposure and 17. Lindsberg, P.J., Strbian, D. & Karjalainen-Lindsberg, M.L. Mast cells as early respond-
whether an autoimmune response develops after subsequent exposure to ers in the regulation of acute blood-brain barrier changes after cerebral ischemia and
hemorrhage. J. Cereb. Blood Flow Metab. 30, 689–702 (2010).
the same antigen, as it may occur in cases of recurrent strokes. Although 18. Strbian, D., Karjalainen-Lindsberg, M.L., Tatlisumak, T. & Lindsberg, P.J. Cerebral
much has been learned on the interplay between the peripheral immu- mast cells regulate early ischemic brain swelling and neutrophil accumulation.
nosuppression and the central immune activation associated with stroke, J. Cereb. Blood Flow Metab. 26, 605–612 (2006).
19. Konsman, J.P., Drukarch, B. & Van Dam, A.M. (Peri)vascular production and action
their impact on short- and long-term tissue outcome remains poorly of pro-inflammatory cytokines in brain pathology. Clin. Sci. (Lond.) 112, 1–25
understood. The fact that the immune system and inflammation are (2007).
20. Sairanen, T.R., Lindsberg, P.J., Brenner, M. & Siren, A.L. Global forebrain ischemia
central to the pathophysiology of stroke has raised the prospect of new results in differential cellular expression of interleukin-1b (IL-1b) and its receptor
therapeutic approaches to counteract ischemic injury. However, under- at mRNA and protein level. J. Cereb. Blood Flow Metab. 17, 1107–1120 (1997).
standing of the crosstalk between the immune system and the ischemic 21. Kono, H. & Rock, K.L. How dying cells alert the immune system to danger. Nat. Rev.
Immunol. 8, 279–289 (2008).

brain is still rudimentary and, as suggested by failed clinical trials, not 22. Bours, M.J., Swennen, E.L., Di Virgilio, F., Cronstein, B.N. & Dagnelie, P.C. Adenosine
adequate to guide therapeutic interventions. Modulation of adaptive 5′-triphosphate and adenosine as endogenous signaling molecules in immunity and
immunity may afford the opportunity to deviate the post-ischemic inflammation. Pharmacol. Ther. 112, 358–404 (2006).
23. Melani, A. et al. ATP extracellular concentrations are increased in the rat striatum
immune response away from tissue damage and toward protection, an during in vivo ischemia. Neurochem. Int. 47, 442–448 (2005).
approach very effective in stroke models. But immunomodulation can 24. Schock, S.C. et al. Cortical spreading depression releases ATP into the extracellular
space and purinergic receptor activation contributes to the induction of ischemic
also have deleterious effects that need to be considered. tolerance. Brain Res. 1168, 129–138 (2007).
The remarkable impact that modulation of the immune system has 25. Burnstock, G. Purinergic signalling and disorders of the central nervous system. Nat.
on stroke damage and repair justifies the aggressive pursuit of basic and Rev. Drug Discov. 7, 575–590 (2008).
26. Bune, L.T., Thaning, P., Johansson, P.I., Bochsen, L. & Rosenmeier, J.B. Effects of
clinical investigations seeking to unravel the fundamental processes gov- nucleotides and nucleosides on coagulation. Blood Coagul. Fibrinolysis 21, 436–441
erning the interaction of the ischemic brain with the immune system. (2010).
27. Pocock, J.M. & Kettenmann, H. Neurotransmitter receptors on microglia. Trends
Acknowledgments Neurosci. 30, 527–535 (2007).
Supported by the US National Institutes of Health grants R37-NS34179 and 28. Peachell, P. Regulation of mast cells by b-agonists. Clin. Rev. Allergy Immunol. 31,
131–142 (2006).
NS35806. We apologize that the scope of the topic prevented citation of many
29. Samson, M.T. et al. Differential roles of CB1 and CB2 cannabinoid receptors in mast
important studies. cells. J. Immunol. 170, 4953–4962 (2003).
30. Marsh, B.J., Williams-Karnesky, R.L. & Stenzel-Poore, M.P. Toll-like receptor sig-
comPetIng InteRests stAtement naling in endogenous neuroprotection and stroke. Neuroscience 158, 1007–1020
The authors declare no competing financial interests. (2009).
31. Hoek, R.M. et al. Down-regulation of the macrophage lineage through interaction
Published online at http://www.nature.com/naturemedicine/ with OX2 (CD200). Science 290, 1768–1771 (2000).
Reprints and permissions information is available online at http://npg.nature.com/ 32. Matsumoto, H. et al. Expression of CD200 by macrophage-like cells in ischemic
reprintsandpermissions/ core of rat brain after transient middle cerebral artery occlusion. Neurosci. Lett. 418,
44–48 (2007).
33. Cardona, A.E. et al. Control of microglial neurotoxicity by the fractalkine receptor.
Nat. Neurosci. 9, 917–924 (2006).
1. Mena, H., Cadavid, D. & Rushing, E.J. Human cerebral infarct: a proposed histo-
34. Chapman, G.A. et al. Fractalkine cleavage from neuronal membranes represents an
pathologic classification based on 137 cases. Acta Neuropathol. 108, 524–530
acute event in the inflammatory response to excitotoxic brain damage. J. Neurosci.
(2004).
20, RC87 (2000).
2. Moskowitz, M.A., Lo, E.H. & Iadecola, C. The science of stroke: mechanisms in search
35. Felger, J.C. et al. Brain dendritic cells in ischemic stroke: time course, activation
of treatments. Neuron 67, 181–198 (2010).
state, and origin. Brain Behav. Immun. 24, 724–737 (2010).
3. Meisel, C., Schwab, J., Prass, K., Meisel, A. & Dirnagl, U. Central nervous sys-
36. Kostulas, N. et al. Dendritic cells are present in ischemic brain after permanent
tem injury–induced immune deficiency syndrome. Nat. Rev. Neurosci. 6, 775–786
middle cerebral artery occlusion in the rat. Stroke 33, 1129–1134 (2002).
(2005).
37. Gelderblom, M. et al. Temporal and spatial dynamics of cerebral immune cell accu-
4. Urra, X., Cervera, A., Villamor, N., Planas, A.M. & Chamorro, A. Harms and benefits
mulation in stroke. Stroke 40, 1849–1857 (2009).
of lymphocyte subpopulations in patients with acute stroke. Neuroscience 158,
38. Yilmaz, A. et al. Transient decrease in circulating dendritic cell precursors after
1174–1183 (2009).
acute stroke: potential recruitment into the brain. Clin. Sci. (Lond.) 118, 147–157
5. Weiner, H.L. The challenge of multiple sclerosis: how do we cure a chronic hetero-
(2009).
geneous disease? Ann. Neurol. 65, 239–248 (2009).
39. Hurn, P.D. et al. T- and B-cell–deficient mice with experimental stroke have
6. Carden, D.L. & Granger, D.N. Pathophysiology of ischaemia-reperfusion injury.
reduced lesion size and inflammation. J. Cereb. Blood Flow Metab. 27, 1798–1805
J. Pathol. 190, 255–266 (2000). (2007).
7. Peerschke, E.I., Yin, W. & Ghebrehiwet, B. Complement activation on platelets: impli- 40. Kleinschnitz, C. et al. Early detrimental T-cell effects in experimental cerebral isch-
cations for vascular inflammation and thrombosis. Mol. Immunol. 47, 2170–2175 emia are neither related to adaptive immunity nor thrombus formation. Blood 115,
(2010). 3835–3842 (2010).
8. Pinsky, D.J. et al. Hypoxia-induced exocytosis of endothelial cell Weibel-Palade 41. Shichita, T. et al. Pivotal role of cerebral interleukin-17–producing gdT cells in the
bodies. A mechanism for rapid neutrophil recruitment after cardiac preservation. delayed phase of ischemic brain injury. Nat. Med. 15, 946–950 (2009).
J. Clin. Invest. 97, 493–500 (1996). 42. Liesz, A. et al. Regulatory T cells are key cerebroprotective immunomodulators in
9. Eltzschig, H.K. & Carmeliet, P. Hypoxia and inflammation. N. Engl. J. Med. 364, acute experimental stroke. Nat. Med. 15, 192–199 (2009).
656–665 (2011). 43. Ren, X., Akiyoshi, K., Vandenbark, A.A., Hurn, P.D. & Offner, H. CD4+FoxP3+ regula-
10. del Zoppo, G.J., Schmid-Schonbein, G.W., Mori, E., Copeland, B.R. & Chang, C.M. tory T-cells in cerebral ischemic stroke. Metab. Brain Dis. 26, 87–90 (2010).
Polymorphonuclear leukocytes occlude capillaries following middle cerebral artery 44. Becker, K.J. et al. Immunologic tolerance to myelin basic protein decreases stroke
occlusion and reperfusion in baboons. Stroke 22, 1276–1283 (1991). size after transient focal cerebral ischemia. Proc. Natl. Acad. Sci. USA 94, 10873–
11. Hyman, M.C. et al. Self-regulation of inflammatory cell trafficking in mice by the 10878 (1997).

review
45. Frenkel, D., et al. Nasal vaccination with myelin oligodendrocyte glycoprotein reduces on spleen lymphocyte subsets and mitogenic response in Wistar rats. Brain Res. 955,
stroke size by inducing IL-10–producing CD4+ T cells. J. Immunol. 171, 6549–6555 85–97 (2002).
(2003). 80. Vogelgesang, A. et al. Functional status of peripheral blood T-cells in ischemic stroke
46. Becker, K., Kindrick, D., McCarron, R., Hallenbeck, J. & Winn, R. Adoptive transfer patients. PLoS ONE 5, e8718 (2010).
of myelin basic protein-tolerized splenocytes to naive animals reduces infarct size: 81. Chamorro, A., Urra, X. & Planas, A.M. Infection after acute ischemic stroke: a mani-
a role for lymphocytes in ischemic brain injury? Stroke 34, 1809–1815 (2003). festation of brain-induced immunodepression. Stroke 38, 1097–1103 (2007).
47. Becker, K.J. Sensitization and tolerization to brain antigens in stroke. Neuroscience 82. Prass, K. et al. Stroke-induced immunodeficiency promotes spontaneous bacterial
158, 1090–1097 (2009). infections and is mediated by sympathetic activation reversal by poststroke T helper
48. Frenkel, D. et al. Neuroprotection by IL-10–producing MOG CD4+ T cells following cell type 1-like immunostimulation. J. Exp. Med. 198, 725–736 (2003).
ischemic stroke. J. Neurol. Sci. 233, 125–132 (2005). 83. Leys, D., Henon, H., Mackowiak-Cordoliani, M.A. & Pasquier, F. Poststroke dementia.
49. Subramanian, S. et al. Recombinant T cell receptor ligand treats experimental stroke. Lancet Neurol. 4, 752–759 (2005).
Stroke 40, 2539–2545 (2009). 84. McColl, B.W., Rothwell, N.J. & Allan, S.M. Systemic inflammatory stimulus poten-
50. Itakura, A. et al. Characterization of human platelet binding of recombinant T cell tiates the acute phase and CXC chemokine responses to experimental stroke and
receptor ligand. J. Neuroinflammation 7, 75 (2010). exacerbates brain damage via interleukin-1– and neutrophil-dependent mechanisms.
51. Abbas, A.K. Basic Immunology Updated Edition: Functions and Disorders of the J. Neurosci. 27, 4403–4412 (2007).
Immune System Ch. 5 (Saunders, 2010). 85. Becker, K.J., Kindrick, D.L., Lester, M.P., Shea, C. & Ye, Z.C. Sensitization to brain
52. Yilmaz, G., Arumugam, T.V., Stokes, K.Y. & Granger, D.N. Role of T lymphocytes and antigens after stroke is augmented by lipopolysaccharide. J. Cereb. Blood Flow
interferon-g in ischemic stroke. Circulation 113, 2105–2112 (2006). Metab. 25, 1634–1644 (2005).
53. Offner, H., Vandenbark, A.A. & Hurn, P.D. Effect of experimental stroke on peripheral 86. Zierath, D. et al. CNS immune responses following experimental stroke. Neurocrit.
immunity: CNS ischemia induces profound immunosuppression. Neuroscience 158, Care 12, 274–284 (2010).
1098–1111 (2009). 87. Fonarow, G.C. et al. Timeliness of tissue-type plasminogen activator therapy in acute
54. Andrews, D.M. & Smyth, M.J. A potential role for RAG-1 in NK cell development ischemic stroke: patient characteristics, hospital factors and outcomes associated
revealed by analysis of NK cells during ontogeny. Immunol. Cell Biol. 88, 107–116 with door-to-needle times within 60 minutes. Circulation 123, 750–758 (2011).
(2010). 88. Gesuete, R. et al. Recombinant C1 inhibitor in brain ischemic injury. Ann. Neurol.
55. Spite, M. & Serhan, C.N. Novel lipid mediators promote resolution of acute inflam- 66, 332–342 (2009).
mation: impact of aspirin and statins. Circ. Res. 107, 1170–1184 (2010). 89. Iadecola, C., Zhang, F. & Xu, X. Inhibition of inducible nitric oxide synthase amelio-
56. Nathan, C. & Ding, A. Nonresolving inflammation. Cell 140, 871–882 (2010). rates cerebral ischemic damage. Am. J. Physiol. 268, R286–R292 (1995).
57. Schilling, M. et al. Predominant phagocytic activity of resident microglia over 90. Lee, S.-T., et al. Anti-inflammatory mechanism of intravascular neural stem cell
hematogenous macrophages following transient focal cerebral ischemia: an investi- transplantation in haemorrhagic stroke. Brain 131, 616–629 (2008).
gation using green fluorescent protein transgenic bone marrow chimeric mice. Exp. 91. Prestigiacomo, C.J. et al. CD18-mediated neutrophil recruitment contributes to the
Neurol. 196, 290–297 (2005). pathogenesis of reperfused but not nonreperfused stroke. Stroke 30, 1110–1117
58. Denes, A. et al. Proliferating resident microglia after focal cerebral ischaemia in mice. (1999).
J. Cereb. Blood Flow Metab. 27, 1941–1953 (2007). 92. Stowe, A.M. et al. Neutrophil elastase and neurovascular injury following focal stroke
59. Rappert, A. et al. CXCR3-dependent microglial recruitment is essential for dendrite and reperfusion. Neurobiol. Dis. 35, 82–90 (2009).
loss after brain lesion. J. Neurosci. 24, 8500–8509 (2004). 93. del Zoppo, G.J. Lessons from stroke trials using anti-inflammatory approaches that
60. Davalos, D. et al. ATP mediates rapid microglial response to local brain injury in vivo. have failed. in Neuroinflammation in Stroke (eds. Dirnagl, U. & Elger, B.) 155–184
Nat. Neurosci. 8, 752–758 (2005). (Springer-Verlagh, Berlin–Heidelberg, 2004).
61. Taylor, A., Verhagen, J., Blaser, K., Akdis, M. & Akdis, C.A. Mechanisms of immune 94. Furuya, K. et al. Examination of several potential mechanisms for the negative out-
suppression by interleukin-10 and transforming growth factor-b: the role of T regula- come in a clinical stroke trial of enlimomab, a murine anti-human intercellular
tory cells. Immunology 117, 433–442 (2006). adhesion molecule-1 antibody: a bedside-to-bench study. Stroke 32, 2665–2674
62. Greenberg, D.A. & Jin, K. Growth factors and stroke. NeuroRx 3, 458–465 (2006). (2001).
63. Carmichael, S.T. Translating the frontiers of brain repair to treatments: starting not 95. Fagan, S.C. et al. Minocycline to improve neurologic outcome in stroke (MINOS): a
to break the rules. Neurobiol. Dis. 37, 237–242 (2010). dose-finding study. Stroke 41, 2283–2287 (2010).
64. Zhang, Z.G., Zhang, L., Jiang, Q. & Chopp, M. Bone marrow–derived endothelial pro- 96. Jensen, H.A. et al. Remote ischemic preconditioning protects the brain against injury
genitor cells participate in cerebral neovascularization after focal cerebral ischemia after hypothermic circulatory arrest. Circulation 123, 714–721 (2011).
in the adult mouse. Circ. Res. 90, 284–288 (2002). 97. Karikó, K., Weissman, D. & Welsh, F.A. Inhibition of Toll-like receptor and cytokine
65. Hayakawa, K., Qiu, J. & Lo, E.H. Biphasic actions of HMGB1 signaling in inflamma- signaling–a unifying theme in ischemic tolerance. J. Cereb. Blood Flow Metab. 24,
tion and recovery after stroke. Ann. NY Acad. Sci. 1207, 50–57 (2010). 1288–1304 (2004).
66. Li, S. et al. An age-related sprouting transcriptome provides molecular control of 98. Marsh, B. et al. Systemic lipopolysaccharide protects the brain from ischemic
axonal sprouting after stroke. Nat. Neurosci. 13, 1496–1504 (2010). injury by reprogramming the response of the brain to stroke: a critical role for IRF3.
67. Lalancette-Hébert, M., Gowing, G., Simard, A., Weng, Y.C. & Kriz, J. Selective J. Neurosci. 29, 9839–9849 (2009).
ablation of proliferating microglial cells exacerbates ischemic injury in the brain. 99. Blondeau, N., Widmann, C., Lazdunski, M. & Heurteaux, C. Activation of the nuclear
J. Neurosci. 27, 2596–2605 (2007). factor-kB is a key event in brain tolerance. J. Neurosci. 21, 4668–4677 (2001).
68. Hayakawa, K., et al. Inhibition of reactive astrocytes with fluorocitrate retards neu- 100. Kunz, A. et al. Neurovascular protection by ischemic tolerance: role of nitric oxide
rovascular remodeling and recovery after focal cerebral ischemia in mice. J. Cereb. and reactive oxygen species. J. Neurosci. 27, 7083–7093 (2007).
Blood Flow Metab. 30, 871–882 (2010). 101. Ohtsuki, T., Ruetzler, C.A., Tasaki, K. & Hallenbeck, J.M. Interleukin-1 mediates
69. Zhang, Z.G. et al. Correlation of VEGF and angiopoietin expression with disruption of induction of tolerance to global ischemia in gerbil hippocampal CA1 neurons.
blood-brain barrier and angiogenesis after focal cerebral ischemia. J. Cereb. Blood J. Cereb. Blood Flow Metab. 16, 1137–1142 (1996).
Flow Metab. 22, 379–392 (2002). 102. Pradillo, J.M., et al. TNFR1 upregulation mediates tolerance after brain ischemic
70. Hao, Q., et al. Neutrophil depletion decreases VEGF-induced focal angiogenesis in preconditioning. J. Cereb. Blood Flow Metab. 25, 193–203 (2005).
the mature mouse brain. J. Cereb. Blood Flow Metab. 27, 1853–1860 (2007). 103. Ziv, Y. et al. A novel immune-based therapy for stroke induces neuroprotection and
71. Manoonkitiwongsa, P.S., Schultz, R.L., McCreery, D.B., Whitter, E.F. & Lyden, P.D. supports neurogenesis. Stroke 38, 774–782 (2007).
Neuroprotection of ischemic brain by vascular endothelial growth factor is critically 104. Steinman, L. A brief history of TH17, the first major revision in the TH1/TH2 hypoth-
dependent on proper dosage and may be compromised by angiogenesis. J. Cereb. esis of T cell–mediated tissue damage. Nat. Med. 13, 139–145 (2007).
Blood Flow Metab. 24, 693–702 (2004). 105. Schwartz, M., London, A. & Shechter, R. Boosting T-cell immunity as a therapeutic
72. Zhang, Z.G. et al. VEGF enhances angiogenesis and promotes blood-brain barrier approach for neurodegenerative conditions: the role of innate immunity. Neuroscience
leakage in the ischemic brain. J. Clin. Invest. 106, 829–838 (2000). 158, 1133–1142 (2009).
73. Denes, A. et al. Experimental stroke-induced changes in the bone marrow reveal com- 106. Genain, C.P. et al. Late complications of immune deviation therapy in a nonhuman
plex regulation of leukocyte responses. J. Cereb. Blood Flow Metab. 31, 1036–1050 primate. Science 274, 2054–2057 (1996).
(2011). 107. Gee, J.M. et al. Long term immunologic consequences of experimental stroke and
74. Jickling, G.C. et al. Signatures of cardioembolic and large-vessel ischemic stroke. mucosal tolerance. Exp. Transl. Stroke Med. 1, 3 (2009).
Ann. Neurol. 68, 681–692 (2010). 108. Schroder, K. & Tschopp, J. The inflammasomes. Cell 140, 821–832 (2010).
75. Offner, H. et al. Experimental stroke induces massive, rapid activation of the periph- 109. Kunz, A. et al. Nuclear factor-kB activation and postischemic inflammation are sup-
eral immune system. J. Cereb. Blood Flow Metab. 26, 654–665 (2006). pressed in CD36-null mice after middle cerebral artery occlusion. J. Neurosci. 28,
76. Emsley, H.C.A. et al. An early and sustained peripheral inflammatory response 1649–1658 (2008).
in acute ischaemic stroke: relationships with infection and atherosclerosis. 110. Arumugam, T.V., Granger, D.N. & Mattson, M.P. Stroke and T-cells. Neuromolecular
J. Neuroimmunol. 139, 93–101 (2003). Med. 7, 229–242 (2005).
77. Smith, C.J. et al. Peak plasma interleukin-6 and other peripheral markers of inflam- 111. Brait, V.H. et al. Mechanisms contributing to cerebral infarct size after stroke: gen-
mation in the first week of ischaemic stroke correlate with brain infarct volume, stroke der, reperfusion, T lymphocytes and Nox2-derived superoxide. J. Cereb. Blood Flow
severity and long-term outcome. BMC Neurol. 4, 2 (2004). Metab. 30, 1306–1317 (2010).
78. Haeusler, K.G. et al. Immune responses after acute ischemic stroke or myocardial 112. Napoli, I. & Neumann, H. Microglial clearance function in health and disease.
infarction. Int. J. Cardiol. published online, doi:10.1016/j.ijcard.2010.10.053 Neuroscience 158, 1030–1038 (2009).
(13 November 2010). 113. Hanayama, R. et al. Autoimmune disease and impaired uptake of apoptotic cells in
79. Gendron, A. et al. Temporal effects of left versus right middle cerebral artery occlusion MFG-E8-deficient mice. Science 304, 1147–1150 (2004).

review
114. Buisson, A. et al. Up-regulation of a serine protease inhibitor in astrocytes medi- blood-borne macrophages. Eur. J. Neurosci. 14, 1651–1658 (2001).
ates the neuroprotective activity of transforming growth factor b1. FASEB J. 12, 127. Mantovani, A., Sica, A. & Locati, M. Macrophage polarization comes of age. Immunity
1683–1691 (1998). 23, 344–346 (2005).
115. Grilli, M. et al. Interleukin-10 modulates neuronal threshold of vulnerability to ischae- 128. Rao, K.N. & Brown, M.A. Mast cells: multifaceted immune cells with diverse roles in
mic damage. Eur. J. Neurosci. 12, 2265–2272 (2000). health and disease. Ann. NY Acad. Sci. 1143, 83–104 (2008).
116. Arai, K., Jin, G., Navaratna, D. & Lo, E.H. Brain angiogenesis in developmental and 129. Borregaard, N. Neutrophils, from marrow to microbes. Immunity 33, 657–670
pathological processes: neurovascular injury and angiogenic recovery after stroke. (2010).
FEBS J. 276, 4644–4652 (2009). 130. Mestas, J. & Hughes, C.C. Of mice and not men: differences between mouse and
117. Jauch, E.C. et al. Association of serial biochemical markers with acute ischemic human immunology. J. Immunol. 172, 2731–2738 (2004).
stroke: the National Institute of Neurological Disorders and Stroke recombinant 131. Kreisel, D. et al. Mouse vascular endothelium activates CD8+ T lymphocytes in a
tissue plasminogen activator Stroke Study. Stroke 37, 2508–2513 (2006). B7-dependent fashion. J. Immunol. 169, 6154–6161 (2002).
118. Bornstein, N.M. et al. Antibodies to brain antigens following stroke. Neurology 56, 132. Wan, Y.Y. Multi-tasking of helper T cells. Immunology 130, 166–171 (2010).
529–530 (2001). 133. Biron, C.A., Nguyen, K.B., Pien, G.C., Cousens, L.P. & Salazar-Mather, T.P. Natural
119. Dambinova, S.A. et al. Blood test detecting autoantibodies to N-methyl-d-aspartate killer cells in antiviral defense: function and regulation by innate cytokines. Annu. Rev.
neuroreceptors for evaluation of patients with transient ischemic attack and stroke. Immunol. 17, 189–220 (1999).
Clin. Chem. 49, 1752–1762 (2003). 134. Bonneville, M., O’Brien, R.L. & Born, W.K. gd T cell effector functions: a blend of innate
120. Rocklin, R.E., Sheremata, W.A., Feldman, R.G., Kies, M.W. & David, J.R. The programming and acquired plasticity. Nat. Rev. Immunol. 10, 467–478 (2010).
Guillain-Barré syndrome and multiple sclerosis. In vitro cellular responses to nervous- 135. Hayday, A.C. gd T cells and the lymphoid stress-surveillance response. Immunity 31,
tissue antigens. N. Engl. J. Med. 284, 803–808 (1971). 184–196 (2009).
121. Gordon, P.H. et al. Efficacy of minocycline in patients with amyotrophic lateral 136. Yanamadala, V. & Friedlander, R.M. Complement in neuroprotection and neurodegen-
sclerosis: a phase III randomised trial. Lancet Neurol. 6, 1045–1053 (2007). eration. Trends Mol. Med. 16, 69–76 (2010).
122. Koch, S., Katsnelson, M., Dong, C. & Perez-Pinzon, M. Remote ischemic limb precon- 137. Strasser, A., Jost, P.J. & Nagata, S. The many roles of FAS receptor signaling in the
ditioning after subarachnoid hemorrhage: a phase Ib study of safety and feasibility. immune system. Immunity 30, 180–192 (2009).
Stroke 42, 1387–1391 (2011). 138. Cui, M. et al. Blocking TRAIL-DR5 signaling with soluble DR5 reduces delayed neu-
123. Lipton, P. Ischemic cell death in brain neurons. Physiol. Rev. 79, 1431–1568 ronal damage after transient global cerebral ischemia. Neurobiol. Dis. 39, 138–147
(1999). (2010).
124. Bacigaluppi, M., Comi, G. & Hermann, D.M. Animal models of ischemic stroke. Part 139. Martin-Villalba, A. et al. CD95 ligand (Fas-L/APO-1L) and tumor necrosis factor-related
one: modeling risk factors. Open Neurol. J. 4, 26–33 (2010). apoptosis-inducing ligand mediate ischemia-induced apoptosis in neurons. J. Neurosci.
125. Ginhoux, F. et al. Fate mapping analysis reveals that adult microglia derive from 19, 3809–3817 (1999).
primitive macrophages. Science 330, 841–845 (2010). 140. Liesz, A. et al. Inhibition of lymphocyte trafficking shields the brain against deleterious
126. Bechmann, I. et al. Immune surveillance of mouse brain perivascular spaces by neuroinflammation after stroke. Brain 134, 704–720 (2011).

Ladecola C, Anrather J. (2012)

Uploaded by

Copyright:

Available Formats

Ladecola C, Anrather J. (2012)

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ladecola C, Anrather J. (2012)

Uploaded by

Copyright:

Available Formats

review

The immunology of stroke: from

796 volume 17 | number 7 | july 2011 nature medicine

nature medicine volume 17 | number 7 | july 2011 797

Table 1 Mediators of post-ischemic inflammation and their producing cells

ATP (Circ, Neu) LOX (Neu, Leuk) Docosanoids (resolvins, protectins)

798 volume 17 | number 7 | july 2011 nature medicine

Figure 2 Cell death and activation of pattern

BOX 1 From ischemia to infarction: the ischemic cascade

nature medicine volume 17 | number 7 | july 2011 799

IL-12 MHC MHC

Neuron TH2 cell IL-10

800 volume 17 | number 7 | july 2011 nature medicine

BOX 2 Cells of the innate immune system

nature medicine volume 17 | number 7 | july 2011 801

IgG TIM4 ‘Eat me’ NGF

802 volume 17 | number 7 | july 2011 nature medicine

BOX 3 The spectrum of lymphocyte subtypes

nature medicine volume 17 | number 7 | july 2011 803

Table 3 Examples of therapeutic approaches targeting multiple inflammatory pathways

804 volume 17 | number 7 | july 2011 nature medicine

BOX 4 How does inflammation kill?

nature medicine volume 17 | number 7 | july 2011 805

Immunol. 8, 279–289 (2008).

806 volume 17 | number 7 | july 2011 nature medicine

nature medicine volume 17 | number 7 | july 2011 807

808 volume 17 | number 7 | july 2011 nature medicine

You might also like