Requirement for preclinical prioritization of neuroprotective strategies in stroke: Incorporation of preconditioning

Acute neuroprotection in numerous human clinical trials has been an abject failure. Major systemic-and procedural-based issues have subsequently been identified in both clinical trials and preclinical animal model experimentation. As well, issues related to the neuroprotective moiety itself have contributed to clinical trial failures, including late delivery, mono-targeting, low potency and poor tolerability. Conditioning (pre-or post-) strategies can potentially address these issues and are therefore gaining increasing attention as approaches to protect the brain from cerebral ischemia. In principle, conditioning can address concerns of timing (preconditioning could be pre-emptively applied in high-risk patients, and post-conditioning after patients experience an unannounced brain infarction) and signaling (multi-modal). However, acute neuroprotection and conditioning strategies face a common translational issue: a myriad of possibilities exist, but with no strategy to select optimal candidates. In this review, we argue that what is required is a neuroprotective framework to identify the "best" agent(s), at the earliest investigational stage possible. This may require switching mindsets from identifying how neuroprotection can be achieved to determining how neuroprotection can fail, for the vast majority of candidates. Understanding the basis for failure can in turn guide supplementary treatment, thereby forming an evidence-based rationale for selecting combinations of therapies. An appropriately designed in vitro (neuron culture, brain slices) approach, based on increasing the harshness of the ischemic-like insult, can be useful in identifying the "best" conditioner or acute neuroprotective therapy, as well as how the two modalities can be combined to overcome individual limitations. This would serve as a base from which to launch further investigation into therapies required to protect the neurovascular unit in in vivo animal models of cerebral ischemia. Based on these respective approaches, our laboratories suggest that there is merit in examining synaptic activity-and nutraceutical-based preconditioning / acute neuroprotection.