Circadian regulation of reperfusion efficacy in acute ischemic stroke

Reperfusion with thrombectomy has changed the clinical landscape for ischemic stroke. Recently, some studies suggest that patients with “large cores” may still benefit from reperfusion. Why? If these “cores” represent dead brain, why should reperfusion help? One logical explanation is that currently used neuroimaging “cores”, do not always identify uniformly dead tissue. Our pilot data suggest that these “cores” include tissue with a wide range of injury, indicated as changes in relative CT Hounsfield Units (rHU). Importantly, circadian mechanisms may be involved. Ischemic tissue with less severe changes in rHU tend to occur in the morning (active phase) when responses to reperfusion are better. In mouse models of stroke, ischemic injury is also less severe when strokes occur during the nighttime (active phase for nocturnal animals). In contrast, more severe ischemic injury during the daytime (inactive phase for mice) is accompanied by dampened vasodilation and CBF response along with increased immunothrombosis and neutrophil extracellular traps (NETosis). Is it possible that understanding these circadian mechanisms may help identify patients who respond best to reperfusion? And is it possible that targeting these circadian mechanisms can help convert non- responders into responders? In this multi-PI project, we use a translational approach (clinical neuroimaging and biomarkers in stroke patients, mouse models of stroke, CT-PET imaging of tissue viability, molecular pharmacology) with three integrated aims that can be pursued in parallel. Aim 1 will use neuroimaging in stroke patients to show that less severe rHU values in reperfusion-responsive “cores” tend to occur in the morning, whereas more severe rHU values in reperfusion-non-responsive “cores” occur later. Aim 2 will use clinical biomarkers to show that more severe rHU “cores” that are not reperfusion-responsive correlate with circadian effects on vasodilation and immunothrombosis. Aim 3 will use mouse stroke models to test whether targeting these circadian mechanisms of vasodilation and immunothrombosis can convert reperfusion-non-responders into reperfusion-responders. Patients cannot choose when they have a stroke. So why should we pay attention to circadian mechanisms? There may be 2 reasons that are addressed by the present project. First, thrombectomy is resource-intensive, and in spite of the very low number-needed-to-treat, only 20% of “large core” patients do well after reperfusion. Our studies may help identify who (when) these responders are. Second, the pathophysiologic mechanisms of cerebral ischemia differ depending on time-of-day. Therefore, understanding and then targeting these circadian mechanisms may allow us to convert reperfusion non-responders into responders. Project Number: 1R01NS149686-01 | Fiscal Year: 2026 | NIH Institute/Center: National Institute of Neurological Disorders and Stroke (NINDS) | Principal Investigator: Eng Lo (+3 co-PIs) | Institution: MASSACHUSETTS GENERAL HOSPITAL, BOSTON, MA | Award Amount: $648,672 | Activity Code: R01 | Study Section: Brain Injury and Neurovascular Disorders Study Section[BIND] View on NIH RePORTER: https://reporter.nih.gov/project-details/11389678