Inhibition of nitric oxide synthase transforms carotid occlusion-mediated benign oligemia into de novo large cerebral infarction

Ha Kim; Jinyong Chung; Jeong Wook Kang; Dawid Schellingerhout; Soo Ji Lee; Hee Jeong Jang; Inyeong Park; Taesu Kim; Dong-Seok Gwak; Ji Sung Lee; Sung-Ha Hong; Kang-Hoon Je; Hee-Joon Bae; Joohon Sung; Eng H Lo; James Faber; Cenk Ayata; Dong-Eog Kim

doi:10.7150/thno.104132

Inhibition of nitric oxide synthase transforms carotid occlusion-mediated benign oligemia into de novo large cerebral infarction

Theranostics. 2025 Jan 1;15(2):585-604. doi: 10.7150/thno.104132. eCollection 2025.

Authors

Ha Kim^{1

2}, Jinyong Chung^{3

2}, Jeong Wook Kang^{1

2}, Dawid Schellingerhout⁴, Soo Ji Lee^{5

6

7}, Hee Jeong Jang^{1

2}, Inyeong Park^{1

2}, Taesu Kim^{1

2}, Dong-Seok Gwak^{1

2}, Ji Sung Lee⁸, Sung-Ha Hong⁹, Kang-Hoon Je^{1

2}, Hee-Joon Bae¹⁰, Joohon Sung^{5

6

7}, Eng H Lo¹¹, James Faber^{12

13

14}, Cenk Ayata^{15

16}, Dong-Eog Kim^{1

3

2}

Affiliations

¹ Department of neurology, Dongguk University Ilsan Hospital, Goyang 10326, Republic of Korea.
² National Priority Research Center for Stroke, Goyang 10326, Republic of Korea.
³ Medical Science Research Center, Dongguk University, Goyang 10326, Republic of Korea.
⁴ Departments of Neuroradiology and Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, TX 77054, USA.
⁵ Genome & Health Big Data Laboratory, Department of Public Health, Graduate School of Public Health, Seoul National University, Seoul 08826, Republic of Korea.
⁶ Health & Environment Institute, Seoul National University, Seoul 08826, Republic of Korea.
⁷ Genomic Medicine Institute, Seoul National University, Seoul 08826, Republic of Korea.
⁸ Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea.
⁹ Center for Translational Neuromedicine, University of Rochester School of Medicine and Dentistry, Rochester, NY 14620, USA.
¹⁰ Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea.
¹¹ Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA.
¹² Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, NC 27599, USA.
¹³ Curriculum in Neuroscience, University of North Carolina, Chapel Hill, NC 27599, USA.
¹⁴ McAllister Heart Institute, University of North Carolina, Chapel Hill, NC 27599, USA.
¹⁵ Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA.
¹⁶ Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02114, USA.

Abstract

Rationale: It remains unclear why unilateral proximal carotid artery occlusion (UCAO) causes benign oligemia in mice, yet leads to various outcomes (asymptomatic-to-death) in humans. We hypothesized that inhibition of nitric oxide synthase (NOS) both transforms UCAO-mediated oligemia into full infarction and expands pre-existing infarction. Methods: Using 900 mice, we i) investigated stroke-related effects of UCAO with/without intraperitoneal administration of the NOS inhibitor (NOSi) N_ω-nitro-L-arginine methyl ester (L-NAME, 400 mg/kg); ii) examined the rescue effect of the NO-donor, molsidomine (200 mg/kg at 30 minutes); and iii) tested the impact of antiplatelet medications. To corroborate preclinical findings, we conducted clinical studies. Results: UCAO alone induced infarction rarely (~2%) or occasionally (~14%) in C57BL/6 and BALB/c mice, respectively. However, L-NAME+UCAO induced large-arterial infarction in ~75% of C57BL/6 and BALB/c mice. Six-hour laser-speckle imaging detected spreading ischemia in ~40% of C57BL/6 and BALB/c mice with infarction (vs. none without) by 24-hours. In agreement with vasoconstriction/microthrombus formation shown by intravital-microscopy, molsidomine and the endothelial-NOS-activating antiplatelet cilostazol attenuated/prevented progression to infarction. Moreover, UCAO without L-NAME caused infarction in ~22% C57BL/6 and ~31% ApoE knock-out mice with hyperglycemia/hyperlipidemia, which associated with ~60% greater levels of symmetric dimethylarginine (SDMA, an endogenous NOSi). Further, increased levels of glucose and cholesterol associated with significantly larger infarct volumes in 438 UCAO-stroke patients. Lastly, Mendelian randomization identified a causative role of NOS inhibition (elevated SDMA concentration) in ischemic stroke risk (OR = 1.24; 95% CI, 1.11-1.38; P = 7.69×10^-5). Conclusion: NOS activity determines the fate of hypoperfused brain following acute UCAO, where SDMA could be a potential risk predictor.

Keywords: carotid artery occlusion; cerebral infarction; nitric oxide synthase; oligemia; stroke.

MeSH terms

Aged
Animals
Cerebral Infarction* / pathology
Disease Models, Animal*
Enzyme Inhibitors / pharmacology
Female
Humans
Male
Mice
Mice, Inbred BALB C*
Mice, Inbred C57BL*
Middle Aged
NG-Nitroarginine Methyl Ester* / pharmacology
Nitric Oxide Synthase* / antagonists & inhibitors
Nitric Oxide Synthase* / metabolism
Stroke

Substances

NG-Nitroarginine Methyl Ester
Nitric Oxide Synthase
Enzyme Inhibitors