Neurochemistry International 165 (2023) 105509

Contents lists available at ScienceDirect

Neurochemistry International
journal homepage: www.elsevier.com/locate/neuint

Oxidative stress: A target to treat Alzheimer’s disease and stroke

Seema Briyal a, *, 1, Amaresh K. Ranjan a, 1, Anil Gulati a, b
a
College of Pharmacy, Midwestern University, Downers Grove, IL, 60515, USA
b
Pharmazz Inc. Research and Development, Willowbrook, IL, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Oxidative stress has been established as a well-known pathological condition in several neurovascular diseases. It
Oxidative stress starts with increased production of highly oxidizing free-radicals (e.g. reactive oxygen species; ROS and reactive
Stroke nitrogen species; RNS) and becomes too high for the endogenous antioxidant system to neutralize them, which
Alzheimer’s disease
results in a significantly disturbed balance between free-radicals and antioxidants levels and causes cellular
Antioxidant therapy
Endothelins
damage. A number of studies have evidently shown that oxidative stress plays a critical role in activating
Sovateltide multiple cell signaling pathways implicated in both progression as well as initiation of neurological diseases.
Endothelin B receptors Therefore, oxidative stress continues to remain a key therapeutic target for neurological diseases. This review
Brain disorders discusses the mechanisms involved in reactive oxygen species (ROS) generation in the brain, oxidative stress, and
pathogenesis of neurological disorders such as stroke and Alzheimer’s disease (AD) and the scope of antioxidant
therapies for these disorders.

1. Introduction mainly of nitric oxide (NO*), peroxynitrite, and other nitrates,

carbon-containing molecules are highly complex in their chemical
Coulomb force interactions between positively charged protons in structure and are usually produced in xenobiotic metabolism (Taysi
the nucleus of the atom and electrons in an electron cloud in the fields et al., 2022). The effect of OS in the brain is highly deleterious and
surrounding the nucleus of the atom are important electrostatic forces known to be involved in the pathogenesis of several neurological dis­
for the stabilization of atoms or ions. A free radical is defined as any orders. Factors contributing to OS in the brain include excitotoxicity and
independently existing species containing one or more unpaired elec­ lipid peroxidation which alters vital mitochondrial functions and re­
trons. To give an example of free radicals, atomic hydrogen (H*) and leases pro-apoptotic proteins. It suggests a direct link between mito­
atomic sodium (Na*) might be some of them (Taysi et al., 2019). Pro­ chondria, oxidative stress, and apoptosis. Excess OS causes structural
duction of free radicals occurs continuously in the cells through enzy­ and functional modifications of cellular biomolecules, thus potentially
matic as well as nonenzymatic reactions. Enzymatic reactions involved limiting neural function and survival (Fig. 1). The development of OS
mainly in the respiratory chain, phagocytosis, the cytochrome P-450 therapeutic strategies is an active area of investigation, which can
system, and prostaglandin synthesis are the major source for producing inhibit the formation of free radicals and prevent the downstream effects
free radicals in the cell. While on the other hand, nonenzymatic free to slow down the disease progression and could be used as drugs for
radicals are mainly generated after reactions of oxygen with organic treating various neurovascular disorders.
compounds and other ionizing reactions in cells (Pham-Huy et al., 2008;
Valko et al., 2007). Reactive oxygen species (ROS), reactive nitrogen
1.1. Oxidative stress in normal and disease conditions in the brain
species (RNS), and other carbon-centered molecules are unstable
chemicals produced under normal physiological and pathophysiological
Reactive oxygen and nitrogen species (ROS/RNS) play important
conditions in biological systems (Cikman et al., 2015; Ercan et al.,
roles in various neurovascular diseases, and other related adverse con­
2021). ROS contains free radical intermediates such as superoxide anion
ditions, such as ischemia (Popa-Wagner et al., 2013). While ROS/RNS
(O2*-), and hydroxyl radical (OH*) as well as non-radical molecules
serve as essential signaling molecules to maintain a normal cellular
such as hydrogen peroxide and hypochlorous acid. While RNS consists
physiological state, their excessive generation in pathological conditions

* Corresponding author. Midwestern University College of Pharmacy, Downers Grove, IL, 60515, USA.
E-mail address: [email protected] (S. Briyal).
1
Equal contribution.

https://doi.org/10.1016/j.neuint.2023.105509
Received 28 September 2022; Received in revised form 1 February 2023; Accepted 5 March 2023
Available online 11 March 2023
0197-0186/© 2023 Elsevier Ltd. All rights reserved.
S. Briyal et al. Neurochemistry International 165 (2023) 105509

and produce a high amount of free radicals.

The uncontrolled generation and accumulation of free radicals in the
brain increases the susceptibility of the neural tissues to damage,
nonetheless the mechanisms by which free radicals cause cerebral tissue
damage are not well understood. Moreover, it is evident that biochem­
ically different neurons have different levels of vulnerability to oxidative
stress. For example, hippocampus, amygdala, and cerebellar granule
cells have been reported as the most susceptible to oxidative stress and
the first to undergo functional decline (Wang and Michaelis, 2010). The
hippocampus exhibits structural plasticity with regenerative/remodel­
ing capacity and undergoes major biochemical changes that ultimately
determine neuronal connections and have significant functional conse­
quences (Popov and Bocharova, 1992; Sousa et al., 2000). It has also
been reported that the amygdala might undergo dendritic alterations
and altered neuronal connectivity in response to stress. Therefore, it
seems highly plausible that oxidative stress in the brain compromises the
biochemical integrity of the hippocampus and the amygdala. It is well
known that the hippocampal DG system regulates structural plasticity,
regenerative/remodeling capacity, as well as neurogenesis factors
(Wang and Michaelis, 2010). Thus, oxidative damage in the brain may
impair remodeling capacity, alter structural plasticity, and affect cell
proliferation as well as neurogenesis, which collectively disturb or
disrupt the complete synaptic neurotransmission or neuro circuitry in
the brain (Salim, 2017). Overall, these complex events following
oxidative stress in the brain ultimately cause functional impairment as
well as compromise the neural tissue regeneration immensely, leading to
unrepaired tissue damage. Therefore, targeting the oxidative stress in its
earliest phase with modulation of the abundance of prooxidants and
antioxidants in the brain would provide an effective therapeutic option,
which could be used to improve neuroprotection in response to oxida­
tive stress in the brain.

1.2. Oxidative stress and excitotoxicity

Fig. 1. Schematic diagram showing the induction of oxidative stress and its
pathophysiological effects. Excitotoxicity and oxidative stress have been observed as major
factors for almost all neurological disorders. These adverse processes
start with the metabolic anomaly in the brain and go hand in hand to
culminates in oxidative modifications and dysfunction of cellular bio­
cause tissue damage, which undoubtedly shows their strong linkage.
molecules e.g. proteins, lipids, and, nucleic acids. The brain is vital for
However, the degree of interdependency and the causal relationship
the function of the complete central nervous system; therefore, its
between them remains obscure. In normal condition, the cellular anti-
biochemical integrity is the key factor to determine overall neuro­
excitatory and anti-oxidative factors help to maintain the cellular ho­
vascular health (Cobley et al., 2018). Biochemically, the human brain is
meostasis (Bondy and LeBel, 1993). The metabolic imbalance and
a highly complex organ, and it consumes 20% of the total basal oxygen
change in cellular ion concentration cause excitotoxicity in neuronal
(O2), which is a very high proportion of O2 consumption relative to the
cells, which frequently leads to pro-oxidant condition but the high rate
ratio of its weight to total body weight. The high consumption of O2 in
of ROS generation is not always accompanied with the hyperexcited
the brain is required for enhanced mitochondrial oxidative phosphory­
state of neurons (Wang and Qin, 2010).
lation in neuronal cells to support ATP-intensive neuronal activity. Its
Excitotoxicity originates with massive release of the excitatory
dependency on O2 is so high that, even a transient phase of ischemia
neurotransmitters. Glutamate is the major excitatory amino acid (EAA)
during pathological conditions compromises ATP supply and adversely
in the brain and overstimulation of postsynaptic glutamate receptors,
affects neuronal activity and survival. Moreover, it also causes ionic
including the ionotropic N-methyl-D-aspartate (NMDA), α-amino-3-hy­
imbalance, faulty electron transfer in mitochondrial oxidative phos­
droxy-5-methyl-4-isoxazole propionic acid (AMPA), and kainic acid
phorylation, and membrane depolarization in neuronal cells, which re­
(KA) receptors, overexcites neurons and triggers pro-death cascades
sults in excessive production of free radicals (ROS/RNS) and leads to
(Gilgun-Sherki et al., 2002). Primarily, excessive influx of calcium ions
oxidative stress in the brain. This, together with the paucity of oxidative
occurs, followed by endoplasmic reticulum stress, mitochondrial
defense mechanisms, the brain is at high risk for damage in oxidative
dysfunction, generation of high levels of ROS/RNS, and oxidative stress
stress. The exact reason why the brain is susceptible to oxidative stress
damage, leading to neuronal death. Neuronal death by excitotoxicity is a
remains obscure; however, some of the following listed factors, which
common and critical process in several neuro-pathologies, such as
are inherent in the brain characteristics could be the reasons 1) High
stroke, traumatic brain injury, epilepsy, Alzheimer’s disease, Parkin­
oxygen consumption of the brain for high energy needs; 2) Vulnerability
son’s disease, Huntington’s disease, amyotrophic lateral sclerosis, and
of neuronal membranes to free-radicals attack as they are rich in poly­
multiple sclerosis (Ambrogini et al., 2019; Coulter and Eid, 2012; Put­
unsaturated fatty acids; 3) High glutamate level in the brain, which
tachary et al., 2015; Vishnoi et al., 2016). Accumulation of glutamate
could cause excitotoxicity 4) High Ca2+ traffic across neuronal mem­
over-activates downstream signaling pathways, many of which involve a
branes, 5) A modest antioxidant defense mechanisms in the brain with
surge in calcium influx, causing the intracellular calcium concentration
low levels of antioxidants (e.g. catalase; CAT, superoxide dismutase;
to increase and exacerbate ROS levels by phospholipase activation.
SOD, glutathione peroxidase, vitamin E and vitamin C, etc.) and 6) A
Moreover, oxidative stress is partly downstream consequences of exci­
high abundance of Fe (II) in the brain could facilitate the Fenton reaction
totoxicity, resulting from a rise in secondary messenger systems coupled

2
S. Briyal et al. Neurochemistry International 165 (2023) 105509

to the enzymatic generation of free radicals (Coyle and Puttfarcken, Experiments as well as clinical trials are now underway to see if
1993; Doble, 1999; Gilgun-Sherki et al., 2002; Pellegrini-Giampietro mitochondria-targeted antioxidants show efficacy against the pathol­
et al., 1990). Therefore, neuroprotection can be achieved by blocking ogies associated with neurological diseases. These strategies could be
the presynaptic release of glutamate and/or by blocking the excitation of used to protect mitochondria from oxidative damage caused by ROS.
postsynaptic neurons occurring after brain insult (Koles et al., 2016). Therefore, pharmaceutical drugs that can limit the overproduction of
The prevention of glutamate-mediated toxicity has been a suitable ROS in the cells may open a new horizon for the development of a po­
therapeutic strategy in numerous clinical trials for treatment of neuro­ tential therapeutic solution to improve mitochondrial health in a wide
logical disorders (Gilgun-Sherki et al., 2002). range of diseases.

1.3. Oxidative stress and mitochondria 1.4. Oxidative stress and apoptosis

Mitochondria in the cell are key to regulate the cellular physiology as Reactive oxygen species (ROS) are highly reactive and short lived
they are the powerhouse to generate majority of ATPs, which are free-radical molecules. Their production in the cell is highly regulated to
essential for the cells during all physiological and pathological events maintain their amount at the minimum required level. They are essential
(Lewen et al., 2000; Love, 1999). Apart from ATPs they are also pro­ for cellular defense (immune system) and regulation of various physi­
duction centers of ROS, which take part in various cellular and molec­ ological functions such as redox balance and several signaling pathways
ular signaling in both normal as well as in oxidative stress conditions. involved in cell cycle, differentiation, migration, and cell death. The
The brain tissue is highly enriched with mitochondria; hence, their function of ROS is also controlled by cellular antioxidant defense system,
dysregulation, which causes excessive ROS production and contribute which protects cellular biomolecules from reacting with ROS. However,
significantly to the pathology of neurological disorders. Since mito­ excess level of ROS in the cell outperforms the anti-oxidant defense
chondria is the major resource for ROS, which have emerged as a system and causes damage to proteins, lipids, membranes and nucleic
convergent signaling hub regulating diverse developmental, and path­ acids, which could lead to activation of apoptosis (Battistelli et al.,
ological stimuli, development of medical therapies designed to regulate 2016).
mitochondrial ROS production could be an important strategy to Apoptosis in neural cells is one of the mechanisms of cell death that
ameliorate the pathology of neurological diseases. can occur after CNS injury (Broughton et al., 2009; Nakka et al., 2008).
ROS generated by mitochondria, or elsewhere in the cell, can cause Apoptosis could follow either extrinsic or intrinsic apoptotic pathways.
damage to cellular macromolecules, including nucleic acids, lipids, and The extrinsic pathway involves ligation of cell surface death receptors e.
proteins. Although mitochondria are a major source of ROS production, g. TNF and FAS receptors., while intrinsic pathway involves mitochon­
they are themselves get targeted from the damaging effect of free radi­ dria (Gupta, 2003). Studies related to neurovascular diseases in patients
cals. One of these targets is mitochondrial DNA (mtDNA), which encodes as well as in animal models have shown that mitochondria mediated
transfer RNAs, and 2 ribosomal RNAs, all of which are essential for apoptosis is the primary mode of cell death in neurons after neuro­
electron transport and ATP generation by oxidative phosphorylation vascular disease (Chan, 2004; Li and Dewson, 2015; Niizuma et al.,
(Anderson et al., 1981; Orrenius et al., 2007). Thus, oxidative damage 2010). Cytotoxic accumulation of intracellular Ca2+ after oxidative
induced by ROS is probably a major source of mitochondrial genomic stress is known to initiate a series of deleterious events in the cell and
instability leading to respiratory dysfunction. Additionally, oxidative triggers the intrinsic apoptotic pathway (Bano and Nicotera, 2007;
stress and lipid peroxidation in mitochondria cause extensive suppres­ Berliocchi et al., 2005; Niizuma et al., 2010) (Green and Kroemer,
sion of their metabolism. Lipid peroxides alter vital mitochondrial 2004). Bcl-2 family proteins play key roles in determining the integrity
functions, such as respiration and oxidative phosphorylation, inner of mitochondrial membrane after apoptotic stimuli (Li and Dewson,
membrane barrier properties, maintenance of mitochondrial membrane 2015). The mitochondrial membrane integrity may be protected by
potential, and mitochondrial Ca2+ buffering capacity (Panov et al., anti-apoptotic members of the Bcl-2 family (Bcl-2 and Bcl-xl) together
2007; Popa-Wagner et al., 2013). The mitochondrial lipid peroxidation with anti-apoptotic kinases Akt and ERK, which inhibit the
interferes the barrier function of the membrane. Changes in either of pro-apoptotic members of the Bcl-2 family (Bid, Bim, Bax, Bak, and Bad)
these critical functions of mitochondria have formidable consequences and prevent cells from dying apparently by an anti-oxidative mecha­
and often determine the cell’s fate in survival/death signaling pathways nism. In addition, upregulation and activation of caspase-3 have been
(Orrenius et al., 2007). Generation of excessive ROS also affects the found to cause DNA damage and death of neurons in CNS injury
mitochondrial permeability causes release of calcium and pro-apoptotic (Broughton et al., 2009). Thus, oxidative stress and apoptosis are closely
factors into the cytosol (Duchen, 2004; Orrenius, 2004) and leads to the linked phenomena and are involved in the pathophysiology of several
neuronal loss experienced in neurological disorders (Duchen, 2012; chronic as well as acute diseases including autoimmunity, diabetes
Nicholls, 2009; Schinder et al., 1996). Additionally, the excess of mellitus, and several neurological diseases e.g. Alzheimer’s disease and
cytosolic-free Ca2+ caused by overstimulation of glutamate receptors stroke (Kannan and Jain, 2000). Advances in our understanding of how
may overload the mitochondrial proton circuit, which leads to the fail­ ROS enable a switch from survival to death should lead to new strategies
ure in oxidation and an increase in ROS into mitochondria following to prevent or treat these diseases. Several antioxidant defense mecha­
brain insult (Lin and Beal, 2006; Murphy, 2009). The mitochondrial nisms have evolved to protect cell components from the attack of
dysfunction due to oxidative damage could also promote the release of oxidative stress and associated oxidative damage and may demonstrate
mitochondrial inner membrane proteins including cytochrome c into the a potential therapeutic solution to enhance cell survival.
intermembrane space, which later get released into cytosol through
pores on the outer membrane made by pro-apoptotic proteins. The 2. Rationale for targeting oxidative stress in Alzheimer’s disease
release of cytochrome c activates the apoptotic machinery in the cytosol and stroke
(Murphy, 2009). Therefore, mitochondrial dysfunction can induce cell
death by affecting cellular calcium homeostasis, enhancing free radical Oxidative stress is a common factor responsible for the onset and
generation, or releasing apoptogenic proteins and suggest a direct link progression of several prominent diseases of CNS such as stroke and
between mitochondria, oxidative stress, and cell death. Alzheimer’s disease (AD). Oxidative stress continues to remain a key
Hence, mitochondria are a major source of intracellular ROS for­ therapeutic target for neurological diseases due to the unique vulnera­
mation and therefore in need of constant protection from the toxic ac­ bility of the brain to oxidative damage and knowledge that high levels of
tion of these species. Such protection is provided by various ROS mediate neuropathology. Moreover, oxidative stress has been
antioxidants, as well as by multiple enzymatic defense systems. identified in early stages of thesediseases, indicating that their etiologies

3
S. Briyal et al. Neurochemistry International 165 (2023) 105509

are linked to free radicals (Tan et al., 2018). The development of drugs
that breaks the vicious cycles of oxidative stress and neurodegeneration
offer new opportunities. Consideration of antioxidant therapy may be
guided by a strong rationale for oxidative stress in the neurological
disease, which prevent production of free radicals.

2.1. Oxidative stress in Alzheimer’s disease

Alzheimer’s disease (AD), an age-related neurodegenerative disease,

is characterized by neuronal and synaptic loss, formation, and accu­
mulation of extracellular Aβ plaques produced from APP processing and
intracellular neurofibrillary tangles (NFTs) composed of aggregated
hyper-phosphorylated tau proteins in the brain and lead to cognitive
decline (Nisbet et al., 2015; Savva et al., 2009; Terry, 2000). An esti­
mated 6.5 million Americans age 65 and older are living with Alz­
heimer’s dementia in 2022. The numbers are projected to rise nearly
12.7 million by 2050. The estimated economic value of care for people
with AD and other dementia across the United States was nearly $321
billion in 2022 (2021). Presently, the only approved therapies for AD are
the cholinesterase inhibitors, N-methyl-D-aspartate receptor antagonist
and Aduhelm (Aducanumab). Unfortunately, despite tremendous effort
and expenditures, the existing clinical treatments for AD only provide
temporary and limited symptomatic relief and they are failed in treating
or delaying progression of the disease. AD pathophysiology is intricate
as it involves the cholinergic dysfunction, amyloid/tau toxicity, oxida­
tive stress/mitochondrial dysfunction, apoptosis, inflammation, which
may result in neural cell damage in the CNS (DeTure and Dickson, 2019;
Savva et al., 2009). We do not fully understand AD etiology and path­
ogenesis, but a remarkable amount of data supports that oxidative stress
is a major player in the pathology of AD (Huang et al., 2016). However,
it remains obscure whether oxidative stress is a cause in AD or resulted Fig. 2. Oxidative stress in Alzheimer disease.
because of the disease. New emerging data have shown that oxidative
damage could be a very early event in neurodegeneration. Oxidative patients (Arslan et al., 2020; Feng and Wang, 2012). These end products
stress damages nucleic acids, proteins and lipids and potentially opens contribute to impairment of the function of membrane proteins such as
the mitochondrial permeability transition pore, which in turn can glucose and glutamate transporters, GTP-binding proteins, and dysre­
further stimulate ROS production, worsen energy failure and release gulation of ionic transfers and calcium homeostasis, resulting in
pro-apoptotic factors (Redza-Dutordoir and Averill-Bates, 2016). ROS increased ROS and compromised mitochondrial function and degener­
generation in excess amount and simultaneous compromise in the ation of synapses, which ultimately induce an apoptotic cascade and
antioxidant defense mostly results in neuronal cell death in AD (Gandhi lead to neurodegeneration(Gandhi and Abramov, 2012). It has been
and Abramov, 2012; Klein and Ackerman, 2003). Hence, regardless of shown that Aβ deposits were always accompanied with high levels of
whether oxidative stress is a cause or result of neurodegeneration, markers of oxidative stress in transgenic mouse model of AD (Jhoo et al.,
therapeutic measures decreasing the oxidative stress level would be 2004), which suggests the association between oxidative stress and Aβ
essential in reducing AD risk and progression (Fig. 2). deposition and possibly has a positive feedback system. ROS induces
The deposition of Aβ, a peptide that varies in size from 39 to 43 calcium influx via glutamate receptors and triggers excitotoxic re­
amino acids, in the senile plaques in the AD brain is believed to be the sponses leading to cell death. DNA and RNA oxidation is marked by
crucial step in AD pathogenesis, around which many of the current drug increased levels of 8-hydroxy-2-deoxyguanosine (8OHdG) and
developments and clinical trials are arranged (Selkoe, 2001). The 8-hydroxyguanosine (8OHD) which mostly localized in Aβ plaques and
cellular proteolytic processing of an integral membrane protein of un­ NFTs (Arslan et al., 2020). Significantly, elevated levels of 8OHdG and
certain function, amyloid precursor protein (APP), can lead to the gen­ 8OHD have also been reported in the post-mortem AD brains. Reduced
eration of Aβ that readily form aggregates and that have neurotoxic antioxidants level has been reported in the early phase of AD in addition
activities (Behl, 1997; Yankner, 1996). The shift of metabolic process to to oxidative damage of neurovascular system (Arslan et al., 2020; Bal­
the higher production level of Aβ than its clearance is the basis for deiras et al., 2010; Chico et al., 2013; Rinaldi et al., 2003). These anti­
accumulation of Aβ and formation of amyloid plaques in the brain. The oxidants include glutathione (GSH), glutathione peroxidase, catalase,
majority of known APP and presenilin mutations responsible for familial and superoxide dismutase (SOD), which are seen significantly decreased
early AD onset affect APP processing and induce overproduction of Aβ, in early stage of AD onset (Puertas et al., 2012; Torres et al., 2011).
especially Aβ42 (Selkoe, 2001). The accumulated excess Aβ is well Additionally, memory impairments correlate with a decrease in brain
known to induce oxidative stress, either directly or indirectly, and exerts and plasma antioxidants defense mechanism, where GSH plays a very
its neurotoxic effects through the production of free radicals in the brain important role in controlling the endogenous redox potential of cells.
of AD patients. These free-radicals also induce lipid peroxidation and (Feng and Wang, 2012; Thornalley, 1998). Intracellular glutathione
exert important influences on the pathogenesis of AD. Studies have concentration decreases with age in mammalian brain regions including
shown that lipid peroxidation is a major cause of depletion of membrane hippocampus (Donahue et al., 2006; Zhu et al., 2006) which may lead to
phospholipids in AD (Markesbery, 1997). Several breakdown products a situation that the rate of ROS production exceeds its removal and thus
following oxidative stress have been observed in AD brains (Selley et al., induces oxidative stress. Since the afore-mentioned studies show
2002), including malondialdehyde (MDA) and 4-hydroxy-2,3-nonenal oxidative processes as important factors in neurodegeneration, it ap­
(HNE) which are the most highly reactive. They are also reported with pears rational that antioxidants would be important drug targets for
elevated levels in cerebrospinal fluid (CSF), blood, and urine of AD treatment of AD.

4
S. Briyal et al. Neurochemistry International 165 (2023) 105509

2.1.1. Antioxidants for AD prevention and treatment aggregate-induced cellular responses by neutralizing ROS through their
Our knowledge of the pathophysiology of AD has been increased antioxidant properties. Indeed, the use of antioxidant agents from diet
greatly over the past decade, yet the definitive causes remain unclear, showed a significant therapeutic effect on various neurodegenerative
and the cures have been elusive. Extensive research has shown that disorders associated with oxidative stress. Curcumin is the principal
oxidative stress is closely associated with the development of AD and is curcuminoid in turmeric, a yellow spice derived from Curcuma longa,
an early factor in the AD process. In addition to oxidative damage, member of the ginger family indigenous in South Asia and a natural
reduced antioxidant defenses have been reported in early AD (Chico polyphenol compound. Curcumin has several beneficial properties —
et al., 2013). Therefore, the limited specificity of oxidative stress and including anti-inflammatory, antioxidant, and neuroprotective and it
antioxidant markers must be kept in view. Antioxidant therapy, as one of was shown to dose-dependently inhibit the formation of β-amyloid fi­
the promising therapeutic strategies for AD, has been studied for years. brils from Aβ40 and Aβ42, two major species of β-amyloid deposits in the
Antioxidants are comprised of both endogenous and exogenous com­ brain (Dhouib et al., 2017; Hatcher et al., 2008; I et al., 2021). Moreover,
pounds that play a central role in the termination of oxidative chain curcumin enhanced neurogenesis in chronically stressed rats, in aged
reactions by removing the free radical intermediates and preventing or rats and in Aβ-induced model of AD (Dong et al., 2012; Sadegh Malva­
curtailing the damage to cells caused by free-radicals (Tan et al., 2018). jerd et al., 2019; Xu et al., 2007). Resveratrol is another natural poly­
It has been demonstrated that antioxidants such as lipoic acid (also phenolic compound found in grapes and wine, has been shown to have
called thioctic acid), vitamin E, vitamin C and β-carotene helped in anti-inflammatory, antioxidant, and immunomodulatory activities. The
breaking down intracellular and extracellular superoxide radicals and antioxidant properties and/or potent free-radical scavenging activity of
H2O2-cell-damaging compounds before they damage cells (Feng and resveratrol have been reported in several in vitro and in vivo studies,
Wang, 2012; Staehelin, 2005). Additionally, preclinical studies which demonstrated that chronic resveratrol treatment reduced the
completed in recent years have shown antioxidant and neuroprotective production of malondialdehyde and nitrite and restored glutathione and
effects of several polyphenolic compounds, which indicates their po­ protect against neuronal damage in AD (Gomes et al., 2018; Sadi and
tential for development of antioxidant therapies. Konat, 2016; Wang et al., 2018). Additionally, resveratrol not only plays
Vitamin E (tocopherols/tocotrienols) and vitamin C (ascorbate) is a role in the protection against ROS, but it can also modulate important
considered as a scavenging and chain-breaking molecules called direct glial functions, including glutamate uptake activity, GSH, improved
antioxidants. Vitamin E is an essential micronutrient for humans and is functional recovery, and decreased DNA fragmentation and apoptosis
one of the most important antioxidants. Vitamin E scavenges free radi­ (Lu et al., 2013; Schweiger et al., 2017). Thus, there are enough evi­
cals mainly by hydrogen atom transfer reaction obtaining a non-radical dence indicating that these antioxidative compounds could be useful for
product and a vitamin E radical, that may react with another radical to development of effective therapeutics for AD treatment in future.
give a stable product, attack lipids, or react with a reducing agent such Several studies have demonstrated an involvement of endothelin
as vitamin C or ubiquinol to regenerate vitamin E (Gugliandolo et al., (ET) in AD. Endothelin (ET), an endogenous 21 amino acid peptide,
2017; Niki, 2014). An adequate vitamin E level is essential for anatomic produces its biological effects through activation of G-protein-coupled
integrity and physiological function of the Purkinje neurons (Ulatowski receptors: ETA and ETB (Arai et al., 1990; Briyal et al., 2019; Yanagi­
et al., 2014). Evidence from preclinical studies showed that vitamin E sawa et al., 1988). ETA receptors are mainly located on vascular smooth
administration may be beneficial in AD. Additionally, in vitro studies muscle cells and mediate vasoconstriction, whereas ETB receptors are
have shown that vitamin E may be able to counteract oxidative stress mainly located on vascular endothelial cells and mediate vasodilatation
induced by Aβ (Boyd-Kimball et al., 2004; Yatin et al., 2000). Yatin et al. (Goto et al., 1989; Tsukahara et al., 1994). It has long been speculated
demonstrated that vitamin E was able to prevent Aβ42 induced protein that cerebrovascular dysfunction contributes to AD. Aβ has been shown
oxidation, ROS production, and neurotoxicity in primary rat embryonic to decrease cerebral blood flow (CBF) and vasodilator responses (Han
hippocampal neuronal culture, maybe through the scavenging of et al., 2008; Niwa et al., 2000; Paris et al., 2004; Shin et al., 2007).
Aβ-induced free radicals (Yatin et al., 2000). Furthermore, Tamagno However, ET has been demonstrated to be present in the brain and plays
et al. showed that Aβ peptides induced oxidative stress, as demonstrated an important role in the regulation of cerebral and systemic blood cir­
by the increase in 4-hydroxynonenal (HNE), H2O2, lipid peroxidation culation (Gulati et al., 1997; Rebello et al., 1995). It was initially
and thiobarbituric acid reactive substances (TBARS) production, and demonstrated that ET-1 concentrations in the cerebrospinal fluid of
was accompanied by apoptosis, increasing caspase 3 activation, cyto­ patients with AD were lower compared to control, however, subsequent
chrome c release and cleavage of poly-ADP ribose polymerase (PARP) studies indicate that ET-1 like immunoreactivity was significantly
(Tamagno et al., 2003). Moreover, oxidative stress induced Aβ-like increased in the cerebral cortex (frontal and occipital lobes) of AD pa­
substances and apoptosis in rat hippocampus, resulting in cognitive tients (Minami et al., 1995; Yoshizawa et al., 1992). Additionally,
deficit. Reports suggest that memory deficits and apoptosis were pre­ postmortem brain samples of AD patients showed increased expression
vented by vitamin E supplementation, due to its antioxidant action of ET-1 in astrocytes (Zhang et al., 1994). High level of ET-1 in the brain
(Fukui et al., 2005). Additionally, the action of vitamin E was tested might induce neuronal dysfunction in the early stage of AD and indicates
against Aβ toxicity in rats infused with Aβ42, showing that its oral the potential benefit of ET receptor antagonists for treatment. Studies
administration, from three days before Aβ infusion, prevented learning from our group have examined the effect of ETA receptor antagonists on
and memory deficits (Yamada et al., 1999). These studies indicated that Aβ-induced oxidative stress and cognitive dysfunction in an adult rat
vitamin E may be able to counteract Aβ-induced effects and tau hyper­ model of AD. Specific ETA receptor antagonists, BQ123 and
phosphorylation, and have positive action on cognitive performance, BMS182874, significantly improved the spatial memory deficit and
may be a suitable compound to prevent or delay disease progression reduced oxidative stress caused by Aβ. On the other hand, a nonspecific
(Gugliandolo et al., 2017). However, further studies are required to ETA/ETB receptor antagonist, TAK-044, did not show any improvement
obtain clear results about vitamin E and vitamin C efficacy in AD. in spatial memory deficits caused by Aβ (Briyal et al., 2011). Lack of
In recent years, several polyphenolic compounds with strong anti­ improvement with a nonspecific ETA/ETB antagonist indicates
oxidative and neuroprotective effects have been discovered, which involvement of ETB receptors and suggest that ETB receptors could be
could be potential therapeutics for prevention and management of AD. important targets to improve functional recovery in AD.
Polyphenols have been suggested as a complimentary AD therapeutic Interestingly, expression of endothelin B (ETB) receptors has been
based on epidemiological evidence that polyphenol-rich diets correlate observed on vascular cells as well as neural cells in the central nervous
with a reduced incidence of AD. Polyphenols have demonstrated the system (CNS) and play important roles in cell survival and proliferation
ability to inhibit Aβ aggregation thereby neutralizing the protein’s (Dong et al., 2005; Ehrenreich et al., 2000; Vidovic et al., 2008). Rats
damaging effects. Additionally, polyphenols may counteract Aβ deficient in ETB receptor during prenatal period had CNS disturbances

5
S. Briyal et al. Neurochemistry International 165 (2023) 105509

and fatal birth defects. They had significantly decreased neuronal pro­ 2.1.2. From bench to bedside: Successes and failures in antioxidant
genitor cells and increased apoptotic cells in different brain regions development
(Gulati, 2016; Leonard et al., 2015). Besides their importance in the Despite promising pre-clinical research, evidence of an effective
brain development, our group has studied the effect of sovateltide antioxidant-based treatment for AD has had mixed results. Indeed, it has
mediated ETB receptors agonism in a rat model of AD created with been suggested that increased dietary intake of antioxidants may reduce
intracerebroventricular administration of Aβ1-40. We administered the risk of developing AD. So far, whether oxidative stress associated
sovateltide (5 μg/kg, i.v.) and assessed functional outcomes. In behav­ with the disease is responsible for the reduction of antioxidants, or
ioral studies using the Morris Water Maze, Aβ produced a significant whether the low antioxidants contribute to the progression of the dis­
impairment in spatial memory as evidenced by significantly longer ease has not been ascertained. The complex neuropathology involved in
escape latencies and no preference for the quadrant, which previously AD is one of the hurdles in successful drug development and most of the
contained the platform in the probe trial (Briyal et al., 2014). The AD drug trials in past have failed. Of the, 413 AD trials that were per­
observed functional changes after sovateltide treatment concurred with formed during 2002–2012, 99.6% failed to meet their set endpoints
the reduced oxidative stress as measured by decreased level of malon­ (Cummings et al., 2014). As we know that most of the therapeutic ap­
dialdehyde (MDA) and increased levels of reduced glutathione (GSH) proaches have focused mainly on inhibiting neurodegeneration by pre­
and superoxide dismutase (SOD) compared to the vehicle group. vention or clearance of Aβ plaques and/or Tau related AD pathological
Increased level of MDA along with decreased levels of antioxidants GSH pathways. These repeated failures could be due to either inhibition of Aβ
and SOD are hallmarks of oxygen free-radical generation occurring as an alone not being sufficient, and/or that the treatment was initiated too
early event in AD pathology (Cutler et al., 2004; Mark et al., 1997). late to be effective. So far, results have been disappointing, and, to date,
Administration of sovateltide produced a significant preventative effect no disease-modifying drug has been approved for the treatment of AD.
in Aβ induced cognitive impairment in rats, decreased oxidative stress Thus, development of multi-target therapies aiming to promote neural
and improved spatial memory deficit. This suggests that the antioxidant cell regeneration and repair along with controlling the oxidative stress
property of sovateltide may have acts as a possible mechanism in pro­ to improve functional outcomes would be ideal.
tecting the neurons, possibly by increasing the endogenous defensive With the social, economic, and human costs associated with AD on
capacity of the brain to combat oxidative stress in AD (Fig. 3). These the rise, many clinical trials are currently underway for the treatment
improvements were blocked when animals were administered ETB re­ and prevention of this disease. Based on data derived from several
ceptor antagonist, BQ788, thus confirming that the effects were due to observational and epidemiological studies several compounds with
selective stimulation of ETB receptors by sovateltide (Briyal et al., 2014, antioxidant activity have been proposed for prevention of cognitive
2015). We have also observed a significant improvement in learning and decline and treatment of MCI or AD (Mecocci and Polidori, 2012). These
memory deficit, with concurrent decrease in oxidative stress damage in clinical trials focus on antioxidant mechanisms to neuroprotection based
transgenic mouse model of AD after sovateltide treatment (unpublished on hopes of developing new and more effective treatments. In Table 1
data). Therefore, the pharmacological activation of ETB receptors may the main clinical trials with antioxidants in MCI and AD – ongoing or
represent a promising approach to reduce oxidative stress, and neuro­ conducted are reported.
degeneration in AD. These preclinical findings suggest that sovateltide Considering the number of AD patients and corresponding societal
has potential to be developed as an effective drug for treatment of AD as costs, plenty of clinical research have been focused on the potential
it improves learning and memory while reducing oxidative stress in benefits of antioxidants (briefly discussed). Vitamin E, the most potent
animal models. lipophilic chain-breaking antioxidant (Stocker, 2007). Preclinical data
As already mentioned, oxidative stress is an important factor in shows that Vitamin E prevents the oxidative damage induced by
neurodegeneration, so it appears rational that antioxidants will be beta-amyloid in cell culture and delays memory deficits in animal
beneficial in the treatment of AD. Thus, approaches to prevent or reduce models. Vitamin E was the first antioxidant to have been tested in a large
oxidative stress may be an important strategy for protecting neuronal placebo-controlled trial to examine whether vitamin E can delay or
cells and could help in development of new therapeutics useful for AD prevent a clinical diagnosis of Alzheimer disease in elderly persons with
prevention/treatment. While there is a wealth of in vitro and in vivo mild cognitive impairment (Grundman, 2000; Mecocci and Polidori,
evidence that these agents could be promising therapeutic agents, 2012). Similarly, flavonoids, curcumin and resveratrol are the most
clinical trials must confirm their actual potential in patients suffering common polyphenolic compounds in the human diet and are sourced
from AD. easily from several fruits and vegetables, beverages like tea and wine,

Fig. 3. The schematic diagram depicting the antioxidative mechanism of sovateltide in AD and stroke.

6
S. Briyal et al. Neurochemistry International 165 (2023) 105509

Table 1 Table 1 (continued )

Current clinical trials for the antioxidant treatment for Alzheimer’s disease (as of Agent Clinical Trial Sponsor
9/12/2022 according to clinicaltrials.gov). Identifier
Agent Clinical Trial Sponsor Scranton Medical Institute,
Identifier Scranton, Pennsylvania,
Vitamin E, Vitamin C, and NCT00117403 University of Arizona United States
Alpha-lipoic Acid University of California- Merchav clinics, Tel-Aviv,
Irvine Israel
University of California, San CPS Research, Glasgow,
Diego United Kingdom
Wien Center, Mount Sinai Neurim Pharmaceuticals Ltd.
Medical Center, Florida Melatonin NCT00000171 National Institute on Aging
University of Kentucky (NIA) 31 study locations
University of Medicine and Resveratrol NCT01504854 Alzheimer’s Disease
Dentistry of New Jersey Cooperative Study (ADCS)
Neurological Care of CNY, and National Institute on
New York Aging (NIA): 26 study
Case Western Reserve locations
University, Ohio Alphatocopherol and Selenium NCT00040378 Frederick Schmitt
Oregon Health Sciences National Institute on Aging
University, Oregon (NIA)
University of Pennsylvania National Cancer Institute (NCI
Medical University of South 91study locations
Carolina Chromium Chloride and NCT03038282 Metabolic Therapy Inc.
University of Washington, Exercise
Seattle Lipoic acid and fish oil NCT01058941 Oregon Health & Science
Glutathione NCT01713816 University of Minnesota concentrate University, Portland, Oregon,
Ascorbate United States
Dietary Supplement: MitoQ NCT03514875 The University of Nebraska at CerefolinNAC® NCT01370954 Falls Neurology and Memory
(mitochondria-targeting Omaha Center, Hickory, North
antioxidant) Carolina, United States
Mediterranean Diet NCT03841539 University of Kansas Medical R-pramipexole NCT01388478 University of Kansas Medical
Center Center, Kansas City, Kansas,
Fish Oil and Lipoic Acid NCT00090402 Oregon Health and Science United States
University Carvedilol NCT01354444 Johns Hopkins School of
National Institute on Aging Medicine Bayview Campus,
(NIA) Baltimore, Maryland, United
National Center for Research States
Resources (NCRR) Glycine + N-acetylcysteine + NCT04740580 Baylor College of Medicine,
Resveratrol with Glucose, and NCT00678431 VA Medical Center, Bronx, NY Alanine (Dietary Houston, Texas, United States
Malate Supplement)
Hydralazine hydrochloride NCT04842552 Shahid Sadoughi University of Dasatinib + Quercetin NCT04063124 Glenn Biggs Institute for
Medical Sciences Alzheimer’s &
Donepezil and Vitamin E NCT00000173 National Institute on Aging Neurodegenerative Diseases,
(NIA) San Antonio, Texas, United
Alzheimer’s Disease States
Cooperative Study (ADCS) dl-alpha-tocopherol and NCT00235716 VA Medical Center, Bay Pines,
Epigallocatechin-Gallate NCT00951834 Charite University Medicine Memantine Florida, United States and 13
Berlin, Germany other locations
Genistein NCT01982578 Universitat de València, Dasatinib + Quercetin NCT04685590 Wake Forest Health Sciences,
Valencia, Spain Winston-Salem, North
Hospital General Carolina, United States
Universitario, Valencia, Spain Dasatinib and Quercetin NCT04785300 Mayo Clinic in Rochester,
Isolated Erythrocyte NCT01707719 Raffaele Antonelli Incalzi, Minnesota, United States
membrane susceptibility to Campus Bio-Medico Vitamin E and multivitamin NCT00056329 National Institute on Aging
photo-oxidative stress University (NIA)- 22 study locations
omega-3 polyunsaturated fatty NCT00628017 Taipei City Psychiatric Center, Alpha-Tocopherol NCT01594346 New York State Institute for
acids (EPA + DHA) Taiwan Basic Research
Behavioral: Supervised NCT03923712 University of Cadiz, Spain National Institute on Aging
Exercise Program (NIA)
Behavioral: NCT03859245 Yankee Eye Clinic, Eagan, Eunice Kennedy Shriver
Photobiomodulation and Minnesota, United States National Institute of Child
Ketogenic diet Health and Human
Behavioral: Aerobic exercise, NCT03035851 University of Calgary, Development (NICHD)
Stretch and Strength Calgary, Alberta, Canada National Center for
Curcumin C3 Complex NCT00099710 UCLA Medical Center, Complementary and
Westwood, California, United Integrative Health (NCCIH)
States New York State Psychiatric
Cerefolin NAC (a medical food) NCT00597376 Rush Alzheimer’s Disease Institute
Center, Chicago, Illinois, University of California, San
United States Diego
Circadin NCT00940589 Meridien Research, Columbia University
Brooksville, Florida, United Bronx Veterans Medical
States Research Foundation, Inc
Exodon LLC, Mount grape seed polyphenolic NCT02502253 Johns Hopkins University,
Arlington, New Jersey, United extract, resveratrol Baltimore, Maryland, United
States States
NCT00692510 Uppsala, Sweden
(continued on next page)

7
S. Briyal et al. Neurochemistry International 165 (2023) 105509

Table 1 (continued ) examine whether NAC can delay or prevent a clinical diagnosis of Alz­
Agent Clinical Trial Sponsor heimer disease in elderly persons with mild cognitive impairment
Identifier (Pocernich et al., 2011).
AZD3480 inhibits Cytochrome
Ginkgo biloba extract, derived from the leaves of the Ginkgo biloba
P450 1A2, 2C19, 3A4, 2C8, tree, is often touted as a memory aid and is one of the most widely used
2B6 and UGT1A1 activity. herbal remedies for dementia and remains one of the best evaluated and
Cocktail mix (Caffeine, characterized extracts (Weinmann et al., 2010). Clinical studies on the
Bupropion, Rosiglitazone,
treatment of AD with Ginkgo biloba leaf extract have been reported since
Omeprazole, Midazolam,
Bilirubin) 1980s, and many clinical studies have been carried out during the
EGCG and Lifestyle NCT03978052 Barcelonabeta Brain Research following 30 years. However, the benefits of Ginkgo biloba on the
recommendations Center, Barcelona, Spain treatment of AD are still controversial. Several small, early studies
Probucol (induced apoE to NCT02707458 Douglas Hospital Research showed modest improvements in cognitive function for older adults with
Negate Cognitive Centre, Montreal, Quebec,
Deterioration) Canada
dementia. However, several larger studies haven’t confirmed that
Aromatherapy NCT05034107 Universiti Teknologi MARA, Ginkgo biloba extract could prevent memory loss or slow the progression
Kuala Selangor, Selangor, of cognitive decline or Alzheimer’s disease in older adults (Liu et al.,
Malaysia 2019). In our opinion, cognitive impairment judged most of them not
Melatonin NCT03954899 University of Iowa Hospitals
valuable because of conducted in too small population or too short in
& Clinics, Iowa City, Iowa,
United States time of intervention. Clinical trials with longer period of treatment
Grape Powder NCT03361410 University of California, Los would be more appropriate to demonstrate the efficacy of Ginkgo biloba.
Angeles, California, United Our preclinical studies using rodent model of AD indicate that se­
States lective stimulation of ETB receptors via its agonist, sovateltide (PMZ-
Lipoic Acid plus Omega-3 Fatty NCT01780974 Oregon Health & Science
Acids University, Portland, Oregon,
1620, IRL-1620), is highly beneficial as mentioned earlier. Our findings
United States indicate that sovateltide administration results in a reduction of oxida­
Biological: Etanercept Dietary NCT01716637 Brain Matters Research, tive stress and enhance neuroregeneration, ultimately leading to
Supplement: Curcum Luteol Florida, United States improved functional recovery in rodent model of AD (Briyal et al., 2014,
Theaflav LipAcid FishOil
2015). As a result of the positive preclinical findings for the use of
Quercet Resverotr
sovateltide in the treatment of AD, clinical trials (Phase I;
CTRI/2016/11/007509) were initiated to establish the safety, tolera­
and seeds like cocoa beans and grape seeds (Spencer, 2010). Plasma bility and pharmacodynamics of sovateltide in healthy human volun­
concentration of polyphenols is very low compared to other antioxi­ teers for the possible future use of this novel therapy in a variety of
dants, so it is probable that the biological effects of dietary polyphenols neurological disorders. The convincing results of both preclinical effi­
are more related to their ability in modulating cell-signaling pathways cacy studies and Phase I human safety and tolerability studies have
and inflammatory responses rather than to a direct antioxidant activity encouraged us to continue investigating the safety and efficacy of
(Mecocci and Polidori, 2012). Therefore, there are ongoing clinical trial sovateltide in human subjects with mild to moderate Alzheimer’s dis­
on patients with mild-to-moderate AD to study their neuroprotective ease (NCT04052737).
effects in the treatment of AD. Progresses in defining the complex etiopathogenesis of AD consider
Pramipexole and other dopamine agonists have been demonstrated oxidative stress a core aspect as far as both AD onset and progression are
to have neuroprotective effects in vitro and in vivo possibly through concerned. However, clinical trials of antioxidants in prevention or
antioxidant effects, as incubation with pramipexole in cell cultures therapy for AD have brought conflicting conclusions. The possible ex­
increased cellular levels of glutathione (GSH), and glutathione peroxi­ planations of these frustrating results may be due to wrong dose, wrong
dase (GSH-Px) and catalase activities (Le et al., 2000). Multicenter, timing, and unbalanced monotherapy (Brewer, 2010). Furthermore,
randomized, placebo-controlled, double-blind clinical trials are ongoing some key biomarkers such as apolipoprotein E4 (APOE4) were identified
in patients with mild-to-moderate AD. Mitochondrial targeted antioxi­ as a single greatest genetic risk factor for sporadic AD in clinical settings
dant is coenzyme Q10 or ubiquinone, a necessary component of the (Belloy et al., 2019; Liu et al., 2019). Therefore, the relationship be­
mitochondrial respiratory chain. Ubiquinone is the only lipophilic tween antioxidants and APOE is still a mystery and future research
antioxidant endogenously synthesized and can efficiently prevent pro­ targeted on their relationship in context of oxidative stress would be
tein oxidation, lipid peroxidation and the oxidation of DNA, especially of useful. Additionally, study to compare the relative effectiveness of these
mitochondrial DNA. Idebenone is a synthetic analog of coenzyme Q10 antioxidants and cholinesterase inhibitors for different dementia sub­
and has shown neuronal protection against β-amyloid toxicity (Cha­ groups is required.
turvedi and Beal, 2008). Treatment with idebenone in AD in RCTs
showed either significant improvement in behavior, memory and 2.2. Oxidative stress in stroke
attention or dose-dependent slowing of disease progression for up to 2
years (Gutzmann and Hadler, 1998). Additionally, lipoic acid, is the Stroke is a cerebrovascular disorder, which is caused due to inter­
coenzyme of mitochondrial pyruvate dehydrogenase and α-ketogluta­ ruption of blood supply in the brain. According to WHO it is defined as
rate dehydrogenase and exerts powerful mitochondrial antioxidant ac­ the interruption in the blood flow to rapidly developing clinical signs of
tivity by recycling other antioxidants such as vitamin E, vitamin C and focal or global disruption of cerebral function, with signs lasting 24 h or
glutathione, scavenging lipid peroxidation products and ROS and by longer or leading to death with no apparent cause other than vascular
chelating redox-active transition metals. Lipoic acid supplementation origin (Donkor, 2018). Approximately 80% of all strokes involve cere­
reduces memory loss and appears to stabilize cognitive function (Hager bral ischemia, while other 20% are due to intracranial hemorrhage.
et al., 2001). Clinical trials with these compounds are ongoing. Occlusion of blood vessels supplying blood in the brain causes cerebral
N-acetyl cysteine (NAC) is a thiol-containing compound able to ischemia, while their rupture and bleeding in the brain results in hem­
interfere with redox transition of thiols, to modulate redox signaling, to orrhage. In either condition, supply of oxygen and glucose in the brain
reduce lipid peroxidation and to act as a substrate for the synthesis of tissues is severely affected and may cause apoptotic and necrotic cell
GSH, one of the major intracellular antioxidant compounds. In addition death. In all cases, a stroke causes dysfunction and death of neural cells
to the antioxidant properties NAC protects against β-amyloid toxicity and compromises neurological and motor functions that reflects the
through anti-apoptotic signaling pathways. Clinical trials are going on to location and size of the brain area affected (Sekerdag et al., 2018).

8
S. Briyal et al. Neurochemistry International 165 (2023) 105509

Ischemic stroke involves a complex sequence of spatial and temporal parameters (Henry and Chandy, 1998; Marchese et al., 2014; Mishima
events evolving over hours and days. The affected cerebral tissue after et al., 2003; Ranjan et al., 1993; Sciamanna and Lee, 1993, 1993v; van
focal ischemia has an ischemic core surrounded by a “penumbra” region, der Worp et al., 1998, 1998v, 1999an der Worp et al., 1999). However,
which has partial reduction in blood flow due to the presence of they failed later either in pre-clinical trial in adult primates or in clinical
collateral arteries. While, in the ischemic core, a significant reduction of trials in humans, which suggest that supplementation of vitamins in food
blood flow occurs and causes severe deprivation of oxygen, glucose, and has little or no effect on the ischemic stroke associated pathways
other nutrients. Consequently, a total bioenergetics failure in the core is (Ascherio et al., 1999; Rabadi and Kristal, 2007). Use of NAC and LA
imminent, where neurons are unable to maintain the ionic gradients. On have been shown to reduce cerebral infarct volume and improve
the other hand, in the penumbra, neurons remain metabolically active; neurological score in rats (Khan et al., 2004; Panigrahi et al., 1996). A
however, they lose their ability to fire action potentials and become clinical trial phase II with aim to assess the safety of NAC in combination
functionally impaired. After stroke, penumbral neurons usually main­ with alteplase (rt-PA) at the acute phase of ischemic stroke is ongoing.
tain enough energy to sustain their resting membrane potentials, and While a phase III clinical trial is under way with aims to investigate the
when collateral blood flow improves, action potential and function effectiveness and safety of alpha-lipoic acid in patients with diabetes and
could be restored. Thus, ischemic penumbra are areas of the brain where ischemic stroke treated with reperfusion therapy. Other ROS scavengers
neurons are damaged but not killed. Nonetheless, in the absence of early e.g. NXY-059 (disufenton sodium), Tirilazad (U–74006F), Edaravone
reperfusion, ischemic injury progresses in the ischemic penumbra (5-methyl-2-phenyl-4H-pyrazol-3-one) etc. have shown promising ef­
leading to a reduction in penumbra area and expansion of the infarcted fects in the rat model of ischemic stroke(Marshall et al., 2001; Park and
core. Generally, the ischemic core is considered irreversible, whereas the Hall, 1994; Yagi et al., 2009; Zhao et al., 2001); however, most of them
penumbra could be rescued by timely interventions and treatments are either failed to support their efficacy in clinical trials or further
(Broughton et al., 2009; Puig et al., 2018). Ischemic injury of neural testing is required in larger clinical trials. These results indicate that ROS
tissues in the core and penumbra travels through a complex series of scavenging is a highly complex mechanism in the brain of rodents,
biochemical, molecular, and genetic events, which contribute either to primates, and humans. Strategy for ROS degradation - SOD and CAT are
protecting, repairing and recovery of the functional activity or to the most common candidates in this category. Polyethylene
damaging tissues to necrosis. Recent studies on molecular, cellular, and glycol-conjugated SOD (PEG-SOD) and CAT (PEG-CAT) have shown
animal models and postmortem brains have revealed that multiple positive outcomes after intravenous administration. They demonstrated
cellular changes including oxidative stress/mitochondrial dysfunction, reduced lesion volume in stroked rats(Liu et al., 1989). M40401; a SOD
excitotoxicity, inflammatory responses, and marked changes in brain mimetic, EUK-134 and EUK-8; synthetic combined superoxide dis­
lipids and proteins are implicated after stroke (Yesilot et al., 2017). mutase/CAT mimetics have shown reduced infarct volume when
The oxidative stress plays a crucial role in the pathogenesis of cere­ administered in the stroke rat model (Baker et al., 1998; Mollace et al.,
bral ischemia–reperfusion (I/R) injury (Zalba et al., 2007), is caused by 2003; Shimizu et al., 2003). Strategy to curb ROS generation - failure of
overwhelmed increase of reactive oxygen species (ROS) or free-radicals, ROS scavengers in clinical trials has indicated that elimination of
which surpasses the effects of scavenger enzymes and protective anti­ detrimental effects of ROS after its generation is very difficult. Hence,
oxidants (Carbone et al., 2015; Grochowski et al., 2018). Deficit of ox­ curbing ROS production following ischemic stroke onset could be a
ygen (hypoxia) and glucose supply due to disruption of blood flow in the better strategy than others. Inhibitors of NOX and XO are some of the
brain affects the mitochondrial oxidative phosphorylation, which causes well-known candidates in this category. NOX inhibitors apocynin,
insufficient production of ATP and increases the formation of diphenyleneiodonium (DPI), VAS2870, gp91ds-tat and GKT136901
free-radicals (Watts et al., 2013). The hypoxic condition in stroke is also have been studied for stroke treatment, and several studies have re­
known to activate xanthine oxidase (XO) and NADPH oxidases (NOX2 ported their protective effect against ischemic stroke in the MCAO rat
and NOX4), which generate ROS (George and Struthers, 2009; Koju model (Laleu et al., 2010; Rey et al., 2001; Tang et al., 2007, 2008; Wang
et al., 2019). These highly reactive free radicals can directly oxidize and et al., 2006; Williams and Griendling, 2007; Yang et al., 2013). Thus, it
damage macromolecules such as proteins, lipids, and DNA. Indirectly, looks like that NOX inhibition could be an important strategy for
they also initiate mitochondrial dysfunction (Lin and Beal, 2006), reducing ROS production after ischemic stroke; however, further in­
apoptotic cascade (Chen et al., 2011), and signal transduction pathways vestigations are required to find out which NOX isoform and what cell
which may finally lead to death of neural cells. Moreover, various lines types play a major role in NOX mediated ROS production after ischemic
of evidence demonstrate that free radicals are also produced due to stroke. XO inhibitors allopurinol, TEI-6720, febuxostat, Y-700 and
induced excitotoxicity in the brain after stroke (Belov Kirdajova et al., BOF-4272 have shown some beneficial effects in ischemic stroke
2020). Besides ROS, the free radicals produced after excitotoxicity specially on inflammatory indices (Becker et al., 2004; Fukunari et al.,
include reactive nitrogen species (RNS) such as nitric oxide (NO•) and 2004; Muir et al., 2008; Naito et al., 2000; Okamoto et al., 2003). In
peroxynitrite (ONOO− ). The produced ROS and RNS after stroke also several studies, Allopurinol has been effective in reducing symptoms of
provoke inflammatory responses in the brain resulting in the release of ischemic stroke in animal stroke models. In a clinical trial in patients
proinflammatory cytokines and chemokines (Chen et al., 2020; Mittal with acute ischemic stroke with high level of serum uric acid, Allopu­
et al., 2014). Thus, oxidative stress is at the center stage of the patho­ rinol was well tolerated and improved the 3-month brain functional
logical events of ischemic stroke; therefore, targeting pathways of status (Taheraghdam et al., 2014). However, Allopurinol can also
ROS/RNS production and their scavenging may be viable strategies for generate superoxide by reducing/inhibiting XO. TEI-6720, febuxostat,
the treatment of stroke. Y-700 and BOF-4272 are some of other small molecules XO inhibitors,
To mitigate the oxidative stress following stroke, several strategies which are being examined in ischemic stroke because of their reported
have been devised to target the pathways affecting steps of upstream improved potency than allopurinol. Additionally, in Table 2 we have
ROS production to their downstream effects on biomolecules. Some of summarized the main clinical trials with antioxidants in ischemic stroke.
the strategies include ROS scavenging, ROS degradation and curbing Altogether, there are enough evidence to prove that oxidative stress
ROS generation (Abe et al., 1988; Wenjun Li, 2016). Strategy for ROS is at the center-stage of stroke related pathological events, hence tar­
scavenging - such as vitamins, NAC (N-acetyl-L-cysteine), and lipoic acid geting it directly or indirectly is essential for the development of suc­
(LA) are the most used antioxidants in this category. Vitamins E and C, cessful interventions or drugs for ischemic stroke. Our group at
vitamin E analogue (MDL 74,722), modified vitamin C (dehydroascorbic Midwestern University in collaboration with Pharmazz Inc. has inves­
acid; DHA and EPC-K1, a phosphate diester of Vitamins C) have been tigated the role of endothelin B receptors (ETBR) in ischemic stroke. We
reported to be protective in rodent and/or primate ischemic stroke have demonstrated that activation of ETBR by its selective agonist,
models and shown reduced lesion volume and improved behavioral sovateltide (IRL 1620; Tycamzzi®) has beneficial effects on cerebral

9
S. Briyal et al. Neurochemistry International 165 (2023) 105509

Table 2 infract reduction and improvement of neurological as well as motor

Current clinical trials for the antioxidant treatment of cerebral ischemia (as of 9/ functions in MCAO rat model (Briyal et al., 2019; Gulati et al., 2018,
12/2022 according to clinicaltrials.gov). 2021; Leonard et al., 2011, 2012; Leonard and Gulati, 2013; Ranjan
Agent Clinical Trial Sponsor et al., 2020a, 2020b). To explore the oxidative stress in these rats we
Identifier examined the expression of antioxidants (SOD and GSH) and level of
Edaravone Dexborneol NCT05121883 Zhejiang University, lipid peroxidation (measured by malondialdehyde). After 24 h of
Hangzhou, Zhejiang, China ischemic stroke (MCAO) the levels of SOD and GSH were significantly
Acetylcysteine NCT04918719 Lundquist Institute for decreased, while malondialdehyde level was increased, which indicated
Biomedical Innovation at
oxidative stress in these rats after ischemia (Fig. 3). Treatment with
Harbor-UCLA Medical
Center sovateltide reversed these effects, while rats pretreated with ETBR
Melatonin NCT03843008 University of Florida antagonist (BQ788) and vehicle treated showed similar oxidative stress
College of Medicine, damage, indicating that activation of ETBR reduces oxidative stress after
Jacksonville, Florida, ischemic stroke (Leonard et al., 2011). In our recent studies we also
United States
Uric Acid NCT00860366 Comprehensive Stroke
observed that sovateltide (Tycamzzi®) treatment protected mitochon­
Center, Hospital Clínic drial dysfunction, increased mitochondrial fusion and biogenesis, and
Barcelona, Spain- 10 study reduced mitochondria mediated apoptosis in the rat brain after ischemic
locations stroke (Briyal et al., 2019; Ranjan et al., 2020a). At present, sovateltide
NXY-059 NCT00119626 AstraZeneca; Södertälje,
has successfully completed phase III clinical trial as a “first in class” drug
Sweden and Glasgow,
United Kingdom candidate for treatment of ischemic stroke.
Astaxanthine NCT03945526 Indonesia University,
Jakarta, Indonesia 3. Conclusion and future strategies
Edaravone Dexborneol NCT04817527 First Affiliated Hospital of
Xian Jiaotong University,
Xi’an, Shaanxi, China An increasing amount of evidence suggests that oxidative stress is
NXY-059 NCT00061022 AstraZeneca; 258 study important either in primary or in secondary pathophysiological mech­
locations anisms underlying acute CNS injury. In addition, reduction in the
Edaravone NCT00153946 National Cardiovascular
endogenous antioxidant defense system due to environmental and ge­
Center, Suita, Osaka, Japan
Dietary Supplement: POMx NCT02442804 Loma Linda University, netic factors may contribute to oxidative stress progression. A better
California, United States understanding of cellular and molecular mechanisms including altered
alpha lipoic acid NCT04041167 Chonnam National signaling caused by ROS in the brain would provide a useful target for
University Hospital, development of potential interventions and drugs, and subsequently
Gwangju, Korea
promoting health and longevity. Therefore, discovery and development
Edaravone (Injection-Low dose NCT04984577 Capital Medical University,
and high dose) Beijing, China of potent antioxidative agents have been the most promising approaches
Idebenone NCT00887562 Columbia University in the search for treatment of neurological or neurodegenerative
Medical Center, New York, diseases.
United States
Actovegin NCT01582854 Takeda- 15 study locations
Dietary Supplement: Selenium NCT02505295 Mazandaran University of Authors contribution
Medical Sciences
N-Acetyl cysteine NCT04920448 CHU Caen, Normandy, Conceptualization: SB; writing—original draft preparation: SB; wri­
France
ting—review and editing: SB, AKR and AG; Literature search: SB and
NXY-059 NCT00075959 AstraZeneca-64 study
locations AKR; All authors have read and agreed to the published version of the
Atorvastatin Calcium NCT03753555 General Hospital of review article.
ShenYang Military Region,
ShenYang, China
MEXIDOL® NCT02793687 Pharmasoft Declaration of competing interest
(ethylmethylhydroxypyridine
succinate)
Edaravone Injection NCT02430350 Jiangsu Simcere A.G. is a Pharmazz, Inc. employee and has issued and pending pat­
Pharmaceutical Co., Ltd. ents related to the sovateltide studies described in this review. S.B. and
48 study locations A.K.R. declares no competing interests.
KH176 NCT04604548 University of Copenhagen,
Kopenhagen, Denmark
Y-2(Edaravone And Borneol) NCT03495206 OSF Healthcare System d/ Data availability
Sublingual Tablet b/a Saint Francis Medical,
Peoria, Illinois, United Data will be made available on request.
States
ARTIFICIAL GRAVITY NCT04369976 Euromedica-Arogi
COMBINED WITH EXERCISE Rehabilitation Center, Acknowledgments
Thessaloniki, FW, Greece
Remote ischemic conditioning NCT03105141 Xuanwu Hospital, Capital We thank the College of Pharmacy and Core Facility, Midwestern
Medical University,
University, Downers Grove, IL for funding support. We also acknowl­
Beijing, China
G6PD gene deficiency NCT05026489 Hospital Xi’an Jiaotong edge Pharmazz Inc. for providing sovateltide for our preclinical studies.
University
Inhaled nitric oxide NCT04988932 Department of References
Neurosurgery, University
Hospital Bern, Bern,
2021 Alzheimer’s disease facts and figures. Alzheimers Dement 17, 2021, 327–406.
Switzerland
Abe, K., Yuki, S., Kogure, K., 1988. Strong attenuation of ischemic and postischemic
Cilostazol and Probucol (alone NCT00823875 Otsuka Beijing Research brain edema in rats by a novel free radical scavenger. Stroke 19, 480–485.
and in combination) Institute, Beijing, China Ambrogini, P., et al., 2019. Excitotoxicity, neuroinflammation and oxidant stress as
molecular bases of epileptogenesis and epilepsy-derived neurodegeneration: the role
of vitamin E. Biochim. Biophys. Acta, Mol. Basis Dis. 1865, 1098–1112.

10
S. Briyal et al. Neurochemistry International 165 (2023) 105509

Anderson, S., et al., 1981. Sequence and organization of the human mitochondrial Donahue, A.N., et al., 2006. Growth hormone administration to aged animals reduces
genome. Nature 290, 457–465. disulfide glutathione levels in hippocampus. Mech. Ageing Dev. 127, 57–63.
Arai, H., et al., 1990. Cloning and expression of a cDNA encoding an endothelin receptor. Dong, F., et al., 2005. Endothelin-1 enhances oxidative stress, cell proliferation and
Nature 348, 730–732. reduces apoptosis in human umbilical vein endothelial cells: role of ETB receptor,
Arslan, J., Jamshed, H., Qureshi, H., 2020. Early detection and prevention of Alzheimer’s NADPH oxidase and caveolin-1. Br. J. Pharmacol. 145, 323–333.
disease: role of oxidative markers and natural antioxidants. Front. Aging Neurosci. Dong, S., et al., 2012. Curcumin enhances neurogenesis and cognition in aged rats:
12, 231. implications for transcriptional interactions related to growth and synaptic
Ascherio, A., et al., 1999. Relation of consumption of vitamin E, vitamin C, and plasticity. PLoS One 7, e31211.
carotenoids to risk for stroke among men in the United States. Ann. Intern. Med. 130, Donkor, E.S., 2018. Stroke in the 21(st) century: a snapshot of the burden, epidemiology,
963–970. and quality of life. Stroke Res. Treat. 2018, 3238165.
Baker, K., et al., 1998. Synthetic combined superoxide dismutase/catalase mimetics are Duchen, M.R., 2004. Roles of mitochondria in health and disease. Diabetes 53 (Suppl. 1),
protective as a delayed treatment in a rat stroke model: a key role for reactive S96–S102.
oxygen species in ischemic brain injury. J. Pharmacol. Exp. Therapeut. 284, Duchen, M.R., 2012. Mitochondria, calcium-dependent neuronal death and
215–221. neurodegenerative disease. Pflügers Archiv 464, 111–121.
Baldeiras, I., et al., 2010. Oxidative damage and progression to Alzheimer’s disease in Ehrenreich, H., et al., 2000. Endothelin b receptor deficiency is associated with an
patients with mild cognitive impairment. J. Alzheimers Dis. 21, 1165–1177. increased rate of neuronal apoptosis in the dentate gyrus. Neuroscience 95,
Bano, D., Nicotera, P., 2007. Ca2+ signals and neuronal death in brain ischemia. Stroke 993–1001.
38, 674–676. Ercan, K., et al., 2021. Moringa oleifera: a review of its occurrence, pharmacological
Battistelli, M., Malatesta, M., Meschini, S., 2016. Oxidative stress to promote cell death importance and oxidative stress. Mini Rev. Med. Chem. 21, 380–396.
or survival. Oxid. Med. Cell. Longev., 2054650, 2016. Feng, Y., Wang, X., 2012. Antioxidant therapies for Alzheimer’s disease. Oxid. Med. Cell.
Becker, M.A., et al., 2004. Febuxostat (TMX-67), a novel, non-purine, selective inhibitor Longev. 2012, 472932.
of xanthine oxidase, is safe and decreases serum urate in healthy volunteers. Nucleos Fukui, K., et al., 2005. Appearance of amyloid beta-like substances and delayed-type
Nucleot. Nucleic Acids 23, 1111–1116. apoptosis in rat hippocampus CA1 region through aging and oxidative stress.
Behl, C., 1997. Amyloid beta-protein toxicity and oxidative stress in Alzheimer’s disease. J. Alzheimers Dis. 8, 299–309.
Cell Tissue Res. 290, 471–480. Fukunari, A., et al., 2004. Y-700 [1-[3-Cyano-4-(2,2-dimethylpropoxy)phenyl]-1H-
Belloy, M.E., Napolioni, V., Greicius, M.D., 2019. A quarter century of APOE and pyrazole-4-carboxylic acid]: a potent xanthine oxidoreductase inhibitor with hepatic
Alzheimer’s disease: progress to date and the path forward. Neuron 101, 820–838. excretion. J. Pharmacol. Exp. Therapeut. 311, 519–528.
Belov Kirdajova, D., et al., 2020. Ischemia-triggered glutamate excitotoxicity from the Gandhi, S., Abramov, A.Y., 2012. Mechanism of oxidative stress in neurodegeneration.
perspective of glial cells. Front. Cell. Neurosci. 14, 51. Oxid. Med. Cell. Longev., 428010, 2012.
Berliocchi, L., Bano, D., Nicotera, P., 2005. Ca2+ signals and death programmes in George, J., Struthers, A.D., 2009. Role of urate, xanthine oxidase and the effects of
neurons. Philos. Trans. R. Soc. Lond. B Biol. Sci. 360, 2255–2258. allopurinol in vascular oxidative stress. Vasc. Health Risk Manag. 5, 265–272.
Bondy, S.C., LeBel, C.P., 1993. The relationship between excitotoxicity and oxidative Gilgun-Sherki, Y., et al., 2002. Antioxidant therapy in acute central nervous system
stress in the central nervous system. Free Radic. Biol. Med. 14, 633–642. injury: current state. Pharmacol. Rev. 54, 271–284.
Boyd-Kimball, D., et al., 2004. Rodent Abeta(1-42) exhibits oxidative stress properties Gomes, B.A.Q., et al., 2018. Neuroprotective mechanisms of resveratrol in Alzheimer’s
similar to those of human Abeta(1-42): implications for proposed mechanisms of disease: role of SIRT1. Oxid. Med. Cell. Longev., 8152373, 2018.
toxicity. J. Alzheimers Dis. 6, 515–525. Goto, K., et al., 1989. Endothelin activates the dihydropyridine-sensitive, voltage-
Brewer, G.J., 2010. Why vitamin E therapy fails for treatment of Alzheimer’s disease. dependent Ca2+ channel in vascular smooth muscle. Proc. Natl. Acad. Sci. U. S. A.
J. Alzheimers Dis. 19, 27–30. 86, 3915–3918.
Briyal, S., Philip, T., Gulati, A., 2011. Endothelin-A receptor antagonists prevent Green, D.R., Kroemer, G., 2004. The pathophysiology of mitochondrial cell death.
amyloid-beta-induced increase in ETA receptor expression, oxidative stress, and Science 305, 626–629.
cognitive impairment. J. Alzheimers Dis. 23, 491–503. Grochowski, C., et al., 2018. Oxidative stress in cerebral small vessel disease. Role of
Briyal, S., Shepard, C., Gulati, A., 2014. Endothelin receptor type B agonist, IRL-1620, reactive species. Free Radic. Res. 52, 1–13.
prevents beta amyloid (Abeta) induced oxidative stress and cognitive impairment in Grundman, M., 2000. Vitamin E and Alzheimer disease: the basis for additional clinical
normal and diabetic rats. Pharmacol. Biochem. Behav. 120, 65–72. trials. Am. J. Clin. Nutr. 71, 630S–636S.
Briyal, S., et al., 2015. Stimulation of endothelin B receptors by IRL-1620 decreases the Gugliandolo, A., Bramanti, P., Mazzon, E., 2017. Role of vitamin E in the treatment of
progression of Alzheimer’s disease. Neuroscience 301, 1–11. Alzheimer’s disease: evidence from animal models. Int. J. Mol. Sci. 18.
Briyal, S., et al., 2019. Anti-apoptotic activity of ETB receptor agonist, IRL-1620, protects Gulati, A., 2016. Endothelin receptors, mitochondria and neurogenesis in cerebral
neural cells in rats with cerebral ischemia. Sci. Rep. 9, 10439. ischemia. Curr. Neuropharmacol. 14, 619–626.
Broughton, B.R., Reutens, D.C., Sobey, C.G., 2009. Apoptotic mechanisms after cerebral Gulati, A., et al., 1997. Effect of centrally administered endothelin agonists on systemic
ischemia. Stroke 40, e331–e339. and regional blood circulation in the rat: role of sympathetic nervous system.
Carbone, F., et al., 2015. Pathophysiology and treatments of oxidative injury in ischemic Neuropeptides 31, 301–309.
stroke: focus on the phagocytic NADPH oxidase 2. Antioxidants Redox Signal. 23, Gulati, A., et al., 2018. A novel neuroregenerative approach using ET(B) receptor
460–489. agonist, IRL-1620, to treat CNS disorders. Physiol. Res. 67, S95–S113.
Chan, P.H., 2004. Mitochondria and neuronal death/survival signaling pathways in Gulati, A., et al., 2021. Safety and Efficacy of Sovateltide (IRL-1620) in a Multicenter
cerebral ischemia. Neurochem. Res. 29, 1943–1949. Randomized Controlled Clinical Trial in Patients with Acute Cerebral Ischemic
Chaturvedi, R.K., Beal, M.F., 2008. Mitochondrial approaches for neuroprotection. Ann. Stroke. CNS Drugs.
N. Y. Acad. Sci. 1147, 395–412. Gupta, S., 2003. Molecular signaling in death receptor and mitochondrial pathways of
Chen, H., et al., 2011. Oxidative stress in ischemic brain damage: mechanisms of cell apoptosis. Int. J. Oncol. 22, 15–20 (Review).
death and potential molecular targets for neuroprotection. Antioxidants Redox Gutzmann, H., Hadler, D., 1998. Sustained efficacy and safety of idebenone in the
Signal. 14, 1505–1517. treatment of Alzheimer’s disease: update on a 2-year double-blind multicentre study.
Chen, Y., et al., 2020. The role of astrocytes in oxidative stress of central nervous system: J. Neural. Transm. Suppl. 54, 301–310.
a mixed blessing. Cell Prolif. 53, e12781. Hager, K., et al., 2001. Alpha-lipoic acid as a new treatment option for Alzheimer
Chico, L., et al., 2013. Oxidative stress and APO E polymorphisms in Alzheimer’s disease [corrected] type dementia. Arch. Gerontol. Geriatr. 32, 275–282.
and in mild cognitive impairment. Free Radic. Res. 47, 569–576. Han, B.H., et al., 2008. Cerebrovascular dysfunction in amyloid precursor protein
Cikman, O., et al., 2015. Antioxidant activity of syringic acid prevents oxidative stress in transgenic mice: contribution of soluble and insoluble amyloid-beta peptide, partial
l-arginine-Induced acute pancreatitis: an experimental study on rats. Int. Surg. 100, restoration via gamma-secretase inhibition. J. Neurosci. 28, 13542–13550.
891–896. Hatcher, H., et al., 2008. Curcumin: from ancient medicine to current clinical trials. Cell.
Cobley, J.N., Fiorello, M.L., Bailey, D.M., 2018. 13 reasons why the brain is susceptible to Mol. Life Sci. 65, 1631–1652.
oxidative stress. Redox Biol. 15, 490–503. Henry, P.T., Chandy, M.J., 1998. Effect of ascorbic acid on infarct size in experimental
Coulter, D.A., Eid, T., 2012. Astrocytic regulation of glutamate homeostasis in epilepsy. focal cerebral ischaemia and reperfusion in a primate model. Acta Neurochir. 140,
Glia 60, 1215–1226. 977–980.
Coyle, J.T., Puttfarcken, P., 1993. Oxidative stress, glutamate, and neurodegenerative Huang, W.J., Zhang, X., Chen, W.W., 2016. Role of oxidative stress in Alzheimer’s
disorders. Science 262, 689–695. disease. Biomed Rep 4, 519–522.
Cummings, J.L., Ringman, J., Vinters, H.V., 2014. Neuropathologic correlates of trial- Jhoo, J.H., et al., 2004. Beta-amyloid (1-42)-induced learning and memory deficits in
related instruments for Alzheimer’s disease. Am J. Neurodegener Dis. 3, 45–49. mice: involvement of oxidative burdens in the hippocampus and cerebral cortex.
Cutler, R.G., et al., 2004. Involvement of oxidative stress-induced abnormalities in Behav. Brain Res. 155, 185–196.
ceramide and cholesterol metabolism in brain aging and Alzheimer’s disease. Proc. Kannan, K., Jain, S.K., 2000. Oxidative stress and apoptosis. Pathophysiology 7,
Natl. Acad. Sci. U. S. A. 101, 2070–2075. 153–163.
DeTure, M.A., Dickson, D.W., 2019. The neuropathological diagnosis of Alzheimer’s Khan, M., et al., 2004. Administration of N-acetylcysteine after focal cerebral ischemia
disease. Mol. Neurodegener. 14, 32. protects brain and reduces inflammation in a rat model of experimental stroke.
Dhouib, I.B., et al., 2017. Neuroprotective effects of curcumin against acetamiprid- J. Neurosci. Res. 76, 519–527.
induced neurotoxicity and oxidative stress in the developing male rat cerebellum: Klein, J.A., Ackerman, S.L., 2003. Oxidative stress, cell cycle, and neurodegeneration.
biochemical, histological, and behavioral changes. Environ. Sci. Pollut. Res. Int. 24, J. Clin. Invest. 111, 785–793.
27515–27524. Koju, N., et al., 2019. Pharmacological strategies to lower crosstalk between
Doble, A., 1999. The role of excitotoxicity in neurodegenerative disease: implications for nicotinamide adenine dinucleotide phosphate (NADPH) oxidase and mitochondria.
therapy. Pharmacol. Ther. 81, 163–221. Biomed. Pharmacother. 111, 1478–1498.

11
S. Briyal et al. Neurochemistry International 165 (2023) 105509

Koles, L., et al., 2016. Modulation of excitatory neurotransmission by neuronal/glial Panov, A., et al., 2007. Species- and tissue-specific relationships between mitochondrial
signalling molecules: interplay between purinergic and glutamatergic systems. permeability transition and generation of ROS in brain and liver mitochondria of rats
Purinergic Signal. 12, 1–24. and mice. Am. J. Physiol. Cell Physiol. 292, C708–C718.
Laleu, B., et al., 2010. First in class, potent, and orally bioavailable NADPH oxidase Paris, D., et al., 2004. Nilvadipine antagonizes both Abeta vasoactivity in isolated
isoform 4 (Nox4) inhibitors for the treatment of idiopathic pulmonary fibrosis. arteries, and the reduced cerebral blood flow in APPsw transgenic mice. Brain Res.
J. Med. Chem. 53, 7715–7730. 999, 53–61.
Le, W.D., et al., 2000. Antioxidant property of pramipexole independent of dopamine Park, C.K., Hall, E.D., 1994. Dose-response analysis of the effect of 21-aminosteroid
receptor activation in neuroprotection. J. Neural. Transm. 107, 1165–1173. tirilazad mesylate (U-74006F) upon neurological outcome and ischemic brain
Leonard, M.G., Gulati, A., 2013. Endothelin B receptor agonist, IRL-1620, enhances damage in permanent focal cerebral ischemia. Brain Res. 645, 157–163.
angiogenesis and neurogenesis following cerebral ischemia in rats. Brain Res. 1528, Pellegrini-Giampietro, D.E., et al., 1990. Excitatory amino acid release and free radical
28–41. formation may cooperate in the genesis of ischemia-induced neuronal damage.
Leonard, M.G., Briyal, S., Gulati, A., 2011. Endothelin B receptor agonist, IRL-1620, J. Neurosci. 10, 1035–1041.
reduces neurological damage following permanent middle cerebral artery occlusion Pham-Huy, L.A., He, H., Pham-Huy, C., 2008. Free radicals, antioxidants in disease and
in rats. Brain Res. 1420, 48–58. health. Int. J. Biomed. Sci. 4, 89–96.
Leonard, M.G., Briyal, S., Gulati, A., 2012. Endothelin B receptor agonist, IRL-1620, Pocernich, C.B., et al., 2011. Nutritional approaches to modulate oxidative stress in
provides long-term neuroprotection in cerebral ischemia in rats. Brain Res. 1464, Alzheimer’s disease. Curr. Alzheimer Res. 8, 452–469.
14–23. Popa-Wagner, A., et al., 2013. ROS and brain diseases: the good, the bad, and the ugly.
Leonard, M.G., et al., 2015. Selective endothelin-B receptor stimulation increases Oxid. Med. Cell. Longev. 2013, 963520.
vascular endothelial growth factor in the rat brain during postnatal development. Popov, V.I., Bocharova, L.S., 1992. Hibernation-induced structural changes in synaptic
Drug Res. 65, 607–613. contacts between mossy fibres and hippocampal pyramidal neurons. Neuroscience
Lewen, A., Matz, P., Chan, P.H., 2000. Free radical pathways in CNS injury. 48, 53–62.
J. Neurotrauma 17, 871–890. Puertas, M.C., et al., 2012. Plasma oxidative stress parameters in men and women with
Li, M.X., Dewson, G., 2015. Mitochondria and apoptosis: emerging concepts. F1000Prime early stage Alzheimer type dementia. Exp. Gerontol. 47, 625–630.
Rep. 7, 42. Puig, B., Brenna, S., Magnus, T., 2018. Molecular communication of a dying neuron in
Lin, M.T., Beal, M.F., 2006. Mitochondrial dysfunction and oxidative stress in stroke. Int. J. Mol. Sci. 19.
neurodegenerative diseases. Nature 443, 787–795. Puttachary, S., et al., 2015. Seizure-induced oxidative stress in temporal lobe epilepsy.
Liu, T.H., et al., 1989. Polyethylene glycol-conjugated superoxide dismutase and catalase BioMed Res. Int. 2015, 745613.
reduce ischemic brain injury. Am. J. Physiol. 256, H589–H593. Rabadi, M.H., Kristal, B.S., 2007. Effect of vitamin C supplementation on stroke recovery:
Liu, H., Ye, M., Guo, H., 2019. An updated review of randomized clinical trials testing the a case-control study. Clin. Interv. Aging 2, 147–151.
improvement of cognitive function of Ginkgo biloba extract in healthy people and Ranjan, A., et al., 1993. Ascorbic acid and focal cerebral ischaemia in a primate model.
Alzheimer’s patients. Front. Pharmacol. 10, 1688. Acta Neurochir. 123, 87–91.
Love, S., 1999. Oxidative stress in brain ischemia. Brain Pathol. 9, 119–131. Ranjan, A.K., Briyal, S., Gulati, A., 2020a. Sovateltide (IRL-1620) activates neuronal
Lu, C., et al., 2013. Design, synthesis, and evaluation of multitarget-directed resveratrol differentiation and prevents mitochondrial dysfunction in adult mammalian brains
derivatives for the treatment of Alzheimer’s disease. J. Med. Chem. 56, 5843–5859. following stroke. Sci. Rep. 10, 12737.
Marchese, M.E., et al., 2014. The vitamin E isoforms alpha-tocopherol and gamma- Ranjan, A.K., et al., 2020b. Sovateltide (IRL-1620) affects neuronal progenitors and
tocopherol have opposite associations with spirometric parameters: the CARDIA prevents cerebral tissue damage after ischemic stroke. Can. J. Physiol. Pharmacol.
study. Respir. Res. 15, 31. 98, 659–666.
Mark, R.J., et al., 1997. A role for 4-hydroxynonenal, an aldehydic product of lipid Rebello, S., et al., 1995. Systemic hemodynamic and regional circulatory effects of
peroxidation, in disruption of ion homeostasis and neuronal death induced by centrally administered endothelin-1 are mediated through ETA receptors. Brain Res.
amyloid beta-peptide. J. Neurochem. 68, 255–264. 676, 141–150.
Markesbery, W.R., 1997. Oxidative stress hypothesis in Alzheimer’s disease. Free Radic. Redza-Dutordoir, M., Averill-Bates, D.A., 2016. Activation of apoptosis signalling
Biol. Med. 23, 134–147. pathways by reactive oxygen species. Biochim. Biophys. Acta 1863, 2977–2992.
Marshall, J.W., et al., 2001. NXY-059, a free radical–trapping agent, substantially lessens Rey, F.E., et al., 2001. Novel competitive inhibitor of NAD(P)H oxidase assembly
the functional disability resulting from cerebral ischemia in a primate species. Stroke attenuates vascular O(2)(-) and systolic blood pressure in mice. Circ. Res. 89,
32, 190–198. 408–414.
Mecocci, P., Polidori, M.C., 2012. Antioxidant clinical trials in mild cognitive impairment Rinaldi, P., et al., 2003. Plasma antioxidants are similarly depleted in mild cognitive
and Alzheimer’s disease. Biochim. Biophys. Acta 1822, 631–638. impairment and in Alzheimer’s disease. Neurobiol. Aging 24, 915–919.
Minami, M., et al., 1995. Endothelin-1-like immunoreactivity in cerebral cortex of Sadegh Malvajerd, S., et al., 2019. Neuroprotective potential of curcumin-loaded
Alzheimer-type dementia. Prog. Neuro-Psychopharmacol. Biol. Psychiatry 19, nanostructured lipid carrier in an animal model of Alzheimer’s disease: behavioral
509–513. and biochemical evidence. J. Alzheimers Dis. 69, 671–686.
Mishima, K., et al., 2003. Vitamin E isoforms alpha-tocotrienol and gamma-tocopherol Sadi, G., Konat, D., 2016. Resveratrol regulates oxidative biomarkers and antioxidant
prevent cerebral infarction in mice. Neurosci. Lett. 337, 56–60. enzymes in the brain of streptozotocin-induced diabetic rats. Pharm. Biol. 54,
Mittal, M., et al., 2014. Reactive oxygen species in inflammation and tissue injury. 1156–1163.
Antioxidants Redox Signal. 20, 1126–1167. Salim, S., 2017. Oxidative stress and the central nervous system. J. Pharmacol. Exp.
Mollace, V., et al., 2003. The protective effect of M40401, a superoxide dismutase Therapeut. 360, 201–205.
mimetic, on post-ischemic brain damage in Mongolian gerbils. BMC Pharmacol. 3, 8. Savva, G.M., et al., 2009. Age, neuropathology, and dementia. N. Engl. J. Med. 360,
Muir, S.W., et al., 2008. Allopurinol use yields potentially beneficial effects on 2302–2309.
inflammatory indices in those with recent ischemic stroke: a randomized, double- Schinder, A.F., et al., 1996. Mitochondrial dysfunction is a primary event in glutamate
blind, placebo-controlled trial. Stroke 39, 3303–3307. neurotoxicity. J. Neurosci. 16, 6125–6133.
Murphy, M.P., 2009. How mitochondria produce reactive oxygen species. Biochem. J. Schweiger, S., et al., 2017. Resveratrol induces dephosphorylation of Tau by interfering
417, 1–13. with the MID1-PP2A complex. Sci. Rep. 7, 13753.
Naito, S., Nishimura, M., Tamao, Y., 2000. Evaluation of the pharmacological actions and Sciamanna, M.A., Lee, C.P., 1993. Ischemia/reperfusion-induced injury of forebrain
pharmacokinetics of BOF-4272, a xanthine oxidase inhibitor, in mouse liver. mitochondria and protection by ascorbate. Arch. Biochem. Biophys. 305, 215–224.
J. Pharm. Pharmacol. 52, 173–179. Sekerdag, E., Solaroglu, I., Gursoy-Ozdemir, Y., 2018. Cell death mechanisms in stroke
Nakka, V.P., et al., 2008. Molecular mechanisms of apoptosis in cerebral ischemia: and novel molecular and cellular treatment options. Curr. Neuropharmacol. 16,
multiple neuroprotective opportunities. Mol. Neurobiol. 37, 7–38. 1396–1415.
Nicholls, D.G., 2009. Mitochondrial calcium function and dysfunction in the central Selkoe, D.J., 2001. Alzheimer’s disease: genes, proteins, and therapy. Physiol. Rev. 81,
nervous system. Biochim. Biophys. Acta 1787, 1416–1424. 741–766.
Niizuma, K., et al., 2010. Mitochondrial and apoptotic neuronal death signaling Selley, M.L., Close, D.R., Stern, S.E., 2002. The effect of increased concentrations of
pathways in cerebral ischemia. Biochim. Biophys. Acta 92–99, 1802. homocysteine on the concentration of (E)-4-hydroxy-2-nonenal in the plasma and
Niki, E., 2014. Role of vitamin E as a lipid-soluble peroxyl radical scavenger: in vitro and cerebrospinal fluid of patients with Alzheimer’s disease. Neurobiol. Aging 23,
in vivo evidence. Free Radic. Biol. Med. 66, 3–12. 383–388.
Nisbet, R.M., et al., 2015. Tau aggregation and its interplay with amyloid-beta. Acta Shimizu, K., et al., 2003. Protective effect of a new nonpeptidyl mimetic of SOD,
Neuropathol. 129, 207–220. M40401, against focal cerebral ischemia in the rat. Brain Res. 963, 8–14.
Niwa, K., Carlson, G.A., Iadecola, C., 2000. Exogenous A beta1-40 reproduces Shin, H.K., et al., 2007. Age-dependent cerebrovascular dysfunction in a transgenic
cerebrovascular alterations resulting from amyloid precursor protein overexpression mouse model of cerebral amyloid angiopathy. Brain 130, 2310–2319.
in mice. J. Cerebr. Blood Flow Metabol. 20, 1659–1668. Sousa, N., et al., 2000. Reorganization of the morphology of hippocampal neurites and
Okamoto, K., et al., 2003. An extremely potent inhibitor of xanthine oxidoreductase. synapses after stress-induced damage correlates with behavioral improvement.
Crystal structure of the enzyme-inhibitor complex and mechanism of inhibition. Neuroscience 97, 253–266.
J. Biol. Chem. 278, 1848–1855. Spencer, J.P., 2010. Beyond antioxidants: the cellular and molecular interactions of
Orrenius, S., 2004. Mitochondrial regulation of apoptotic cell death. Toxicol. Lett. 149, flavonoids and how these underpin their actions on the brain. Proc. Nutr. Soc. 69,
19–23. 244–260.
Orrenius, S., Gogvadze, V., Zhivotovsky, B., 2007. Mitochondrial oxidative stress: Staehelin, H.B., 2005. Micronutrients and Alzheimer’s disease. Proc. Nutr. Soc. 64,
implications for cell death. Annu. Rev. Pharmacol. Toxicol. 47, 143–183. 565–570.
Panigrahi, M., et al., 1996. alpha-Lipoic acid protects against reperfusion injury Stocker, R., 2007. Vitamin E. Novartis Found Symp. 282, 77–87. ; discussion 87-92, 212-
following cerebral ischemia in rats. Brain Res. 717, 184–188. 8.

12
S. Briyal et al. Neurochemistry International 165 (2023) 105509

Taheraghdam, A.A., et al., 2014. Allopurinol as a preventive contrivance after acute Wang, Q., et al., 2006. Apocynin protects against global cerebral ischemia-reperfusion-
ischemic stroke in patients with a high level of serum uric acid: a randomized, induced oxidative stress and injury in the gerbil hippocampus. Brain Res. 1090,
controlled trial. Med. Princ. Pract. 23, 134–139. 182–189.
Tamagno, E., et al., 2003. Multiple signaling events in amyloid beta-induced, oxidative Wang, H., et al., 2018. Resveratrol attenuates oxidative damage through activating
stress-dependent neuronal apoptosis. Free Radic. Biol. Med. 35, 45–58. mitophagy in an in vitro model of Alzheimer’s disease. Toxicol. Lett. 282, 100–108.
Tan, B.L., et al., 2018. Antioxidant and oxidative stress: a mutual interplay in age-related Watts, L.T., et al., 2013. Stroke neuroprotection: targeting mitochondria. Brain Sci. 3,
diseases. Front. Pharmacol. 9, 1162. 540–560.
Tang, L.L., et al., 2007. Apocynin attenuates cerebral infarction after transient focal Weinmann, S., et al., 2010. Effects of Ginkgo biloba in dementia: systematic review and
ischaemia in rats. J. Int. Med. Res. 35, 517–522. meta-analysis. BMC Geriatr. 10, 14.
Tang, X.N., et al., 2008. Apocynin improves outcome in experimental stroke with a Wenjun Li, S.Y., 2016. Targeting oxidative stress for the treatment of ischemic stroke:
narrow dose range. Neuroscience 154, 556–562. upstream and downstream therapeutic strategies. Brain Circ 2, 153–163.
Taysi, S., et al., 2019. Radicals, oxidative/nitrosative stress and preeclampsia. Mini Rev. Williams, H.C., Griendling, K.K., 2007. NADPH oxidase inhibitors: new antihypertensive
Med. Chem. 19, 178–193. agents? J. Cardiovasc. Pharmacol. 50, 9–16.
Taysi, S., et al., 2022. Thymoquinone: a review on its pharmacological importance, and Xu, Y., et al., 2007. Curcumin reverses impaired hippocampal neurogenesis and increases
its association with oxidative stress, COVID-19, and radiotherapy. Mini Rev. Med. serotonin receptor 1A mRNA and brain-derived neurotrophic factor expression in
Chem. 22, 1847–1875. chronically stressed rats. Brain Res. 1162, 9–18.
Terry, R.D., 2000. Cell death or synaptic loss in Alzheimer disease. J. Neuropathol. Exp. Yagi, K., et al., 2009. Edaravone, a free radical scavenger, inhibits MMP-9-related brain
Neurol. 59, 1118–1119. hemorrhage in rats treated with tissue plasminogen activator. Stroke 40, 626–631.
Thornalley, P.J., 1998. Glutathione-dependent detoxification of alpha-oxoaldehydes by Yamada, K., et al., 1999. Protective effects of idebenone and alpha-tocopherol on beta-
the glyoxalase system: involvement in disease mechanisms and antiproliferative amyloid-(1-42)-induced learning and memory deficits in rats: implication of
activity of glyoxalase I inhibitors. Chem. Biol. Interact. 111–112, 137–151. oxidative stress in beta-amyloid-induced neurotoxicity in vivo. Eur. J. Neurosci. 11,
Torres, L.L., et al., 2011. Peripheral oxidative stress biomarkers in mild cognitive 83–90.
impairment and Alzheimer’s disease. J. Alzheimers Dis. 26, 59–68. Yanagisawa, M., et al., 1988. A novel potent vasoconstrictor peptide produced by
Tsukahara, H., et al., 1994. Molecular and functional characterization of the non- vascular endothelial cells. Nature 332, 411–415.
isopeptide-selective ETB receptor in endothelial cells. Receptor coupling to nitric Yang, X.Y., et al., 2013. Inhibition of NADPH oxidase mediates protective effect of
oxide synthase. J. Biol. Chem. 269, 21778–21785. cardiotonic pills against rat heart ischemia/reperfusion injury. Evid Based
Ulatowski, L., et al., 2014. Vitamin E is essential for Purkinje neuron integrity. Complement Alternat. Med., 728020, 2013.
Neuroscience 260, 120–129. Yankner, B.A., 1996. Mechanisms of neuronal degeneration in Alzheimer’s disease.
Valko, M., et al., 2007. Free radicals and antioxidants in normal physiological functions Neuron 16, 921–932.
and human disease. Int. J. Biochem. Cell Biol. 39, 44–84. Yatin, S.M., Varadarajan, S., Butterfield, D.A., 2000. Vitamin E prevents Alzheimer’s
van der Worp, H.B., et al., 1998. Dietary vitamin E levels affect outcome of permanent amyloid beta-peptide (1-42)-induced neuronal protein oxidation and reactive
focal cerebral ischemia in rats. Stroke 29, 1002–1005. ; discussion 1005-6. oxygen species production. J. Alzheimers Dis. 2, 123–131.
van der Worp, H.B., et al., 1999. Inhibition of iron-dependent and ischemia-induced Yesilot, N., et al., 2017. Ethnic and geographical differences in ischaemic stroke among
brain damage by the alpha-tocopherol analogue MDL 74,722. Exp. Neurol. 155, young adults. Curr. Vasc. Pharmacol. 15, 416–429.
103–108. Yoshizawa, T., et al., 1992. Cerebrospinal fluid endothelin-1 in Alzheimer’s disease and
Vidovic, M., et al., 2008. Deficiency in endothelin receptor B reduces proliferation of senile dementia of Alzheimer type. Neuropeptides 22, 85–88.
neuronal progenitors and increases apoptosis in postnatal rat cerebellum. Cell. Mol. Zalba, G., et al., 2007. Oxidative stress, endothelial dysfunction and cerebrovascular
Neurobiol. 28, 1129–1138. disease. Cerebrovasc. Dis. 24 (Suppl. 1), 24–29.
Vishnoi, S., Raisuddin, S., Parvez, S., 2016. Glutamate excitotoxicity and oxidative stress Zhang, W.W., et al., 1994. Astrocytes in Alzheimer’s disease express immunoreactivity to
in epilepsy: modulatory role of melatonin. J. Environ. Pathol. Toxicol. Oncol. 35, the vaso-constrictor endothelin-1. J. Neurol. Sci. 122, 90–96.
365–374. Zhao, Z., et al., 2001. NXY-059, a novel free radical trapping compound, reduces cortical
Wang, X., Michaelis, E.K., 2010. Selective neuronal vulnerability to oxidative stress in infarction after permanent focal cerebral ischemia in the rat. Brain Res. 909, 46–50.
the brain. Front. Aging Neurosci. 2, 12. Zhu, Y., Carvey, P.M., Ling, Z., 2006. Age-related changes in glutathione and
Wang, Y., Qin, Z.H., 2010. Molecular and cellular mechanisms of excitotoxic neuronal glutathione-related enzymes in rat brain. Brain Res. 1090, 35–44.
death. Apoptosis 15, 1382–1402.

13