Puerarin protects brain tissue against cerebral ischemia/reperfusion injury by inhibiting the in fl ammatory response

Feng Zhou, Liang Wang,, Panpan Liu, Weiwei Hu, Xiangdong Zhu, Hong Shen, Yuanyuan Yao

1 Department of Neurosurgery, Second Af fi liated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China

2 Medical College, Ningbo University, Ningbo, Zhejiang Province, China

3 Department of Anesthesiology, Second Af fi liated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China

Puerarin protects brain tissue against cerebral ischemia/reperfusion injury by inhibiting the in fl ammatory response

Feng Zhou1, Liang Wang1,2, Panpan Liu1, Weiwei Hu1, Xiangdong Zhu1, Hong Shen1, Yuanyuan Yao3

1 Department of Neurosurgery, Second Af fi liated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China

2 Medical College, Ningbo University, Ningbo, Zhejiang Province, China

3 Department of Anesthesiology, Second Af fi liated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China

Puerarin, a traditional Chinese medicine, exerts a powerful neuroprotective effect in cerebral ischemia/reperfusion injury, but its mechanism is unknown. Here, we established rat models of middle cerebral artery ischemia/reperfusion injury using the suture method. Puerarin (100 mg/kg) was administered intraperitoneally 30 minutes before middle cerebral artery occlusion and 8 hours after reperfusion. Twenty-four hours after reperfusion, we found that puerarin signi fi cantly improved neurological de fi cit, reduced infarct size and brain water content, and notably diminished the expression of Toll-like receptor-4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-α in the ischemic region. These data indicate that puerarin exerts an anti-in fl ammatory protective effect on brain tissue with ischemia/reperfusion damage by downregulating the expression of multiple in fl ammatory factors.

nerve regeneration; brain injury; puerarin; cerebral ischemia; reperfusion injury; rats; inflammatory reaction; Toll-like receptor-4; nuclear factor kappa B; myeloid differentiation factor 88; tumor necrosis factor-α; middle cerebral artery occlusion; neural regeneration

Funding: This study was supported by the Chinese Traditional Medical Science Foundation of Zhejiang Province in China, No. 2010ZA072; the Health Bureau Foundation of Zhejiang Province in China, No. 2012ZDA023; and the Qianjiang Project of Zhejiang Science and Technology Bureau in China, No. 2010 R10073.

Zhou F, Wang L, Liu PP, Hu WW, Zhu XD, Shen H, Yao YY. Puerarin protects brain tissue against cerebral ischemia/reperfusion injury by inhibiting the inflammatory response. Neural Regen Res. 2014;9(23):2074-2080.

Introduction

Cerebral ischemia/reperfusion injury can trigger a strong in fl ammatory response (Lenardo et al, 1989; Vila et al., 2000; Liao et al., 2001). Immune and in fl ammatory responses are intrinsic to neuronal injury induced by cerebral ischemia and reperfusion (Danton et al., 2003; Monje et al., 2003; Hayden et al., 2004; Huang et al., 2006; Wong et al., 2008). Nuclear factor kappa B is an important transcription factor and a central mediator of the inflammatory response. It initiates the transcription of genes associated with the immune response and in fl ammation, including tumor necrosis factor-α, interleukin-1, interleukin-6 and inducible nitric oxide synthase, which all contribute to the adverse outcomes induced by cerebral ischemia/reperfusion injury (Lindsberg et al., 2003; Leeman et al., 2008; Lambertsen et al., 2012; Yang et al., 2013). Nuclear factor kappa B can be activated by various stimulating factors, including cytokines and bacteria (Zhou et al., 2012; Liu et al., 2014). These stimulating factors can be identi fi ed by speci fi c receptor families such as Toll-like receptors (Schneider et al., 1999; Kumar et al., 2004; Ridder et al., 2009; Baker et al., 2011), a large class of signal transduction molecules that are involved in inherent and adaptive immunity (Aderem et al., 2000; Takeda, 2005; Akira, 2006). Toll-like receptor 4 was the fi rst Toll-like receptor to be found in mammals, and its expression is associated with many central nervous system diseases, such as in fl ammatory autoimmune diseases and cerebral ischemic injury (Kerfoot et al., 2004; Cao et al., 2006; Hua et al., 2007, 2009). Stimulation of Toll-like receptor 4 triggers a signaling pathway, activating NF-kB transcription through the dependent or independent myeloid differentiation factor 88 pathway, and resulting in the expression of inflammatory response factors such as tumor necrosis factor-α and interleukin-1 (Hallenbeck et al., 2002; Janeway et al., 2002; Kaczorowski et al., 2009; Ishizuka et al., 2013).

Puerarin (C21H20O9, relative molecular weight 416.38) is a major isoflavonoid, extracted from the traditional Chinese medicine Radix puerariae (kudzu root) (Wang et al., 2012; Chen et al., 2013), and is used to treat many conditions including ischemic cerebrovascular disease (Wang et al., 1997, 2014; Sang et al., 2001; Ding et al., 2007; Wu et al., 2007). Isofl avones in food improve the outcome of cerebral ischemic injury, reducing infarct volume and improving neurological function (Pan et al., 2005; Burguete et al., 2006; Zhang etal., 2008; Tian et al., 2013). Puerarin scavenges free radicals, increases cerebral blood fl ow, and exerts neuroprotective and anti-inflammatory effects in ischemia/reperfusion injury (Xu et al., 2005; Han et al., 2007; Zhao et al., 2007; Chang et al., 2009). However, the mechanism underlying these effects of puerarin in cerebral ischemia/reperfusion injury remains poorly understood. In the present study, we observed the effects of puerarin on in fl ammatory molecules in the Toll-like receptor 4-mediated NF-kB signaling pathway, and investigated the mechanism by which the drug exerts cerebral protection in a rat model of middle cerebral artery occlusion.

Table 1 Primer sequence for PCR

Materials and Methods

Animals and experimental groups

Thirty-six male 8-week-old Sprague-Dawley rats, weighing 250—280 g, were housed at 22—24°C with a normal light/dark cycle. The rats were allowed free access to food and water. Body temperature, heart rate, blood pressure, blood sugar, arterial blood pH, pO2and pCO2in experimental rats were monitored before artery occlusion, before reperfusion and 30 minutes after reperfusion, and no signi fi cant differences were detected between groups. Experimental protocols were conducted in accordance with the Animal Experiments Ethics Committee of Zhejiang University, China.

In the fi rst experiment, 18 rats were equally and randomly divided into three groups: puerarin treatment, vehicle control, and sham surgery control. The vehicle and puerarin groups were subjected to middle cerebral artery occlusion for 90 minutes. Rats in the sham surgery group underwent the same surgical procedures except for occlusion of the middle cerebral artery. Thirty minutes before middle cerebral artery occlusion and 8 hours after reperfusion, rats in the puerarin group received an intraperitoneal injection of puerarin (100 mg/kg; Zhejiang CONBA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang Province, China). Rats in the vehicle and sham surgery groups received an equal dose of physiological saline. Twenty-four hours after reperfusion, the neurological function was evaluated by an examiner blinded to the experimental groups. The animals were then decapitated under deep 10% chloral hydrate anesthesia (800 mg/kg intraperitoneally) and brain tissues were harvested quickly to observe the effects of puerarin on infarct size and water content.

In the second experiment, 18 rats were equally and randomly assigned into the same three groups and underwent the same surgical procedures as in the fi rst experiment, and the mRNA and protein expression of Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-α in ischemic brain tissue was measured by real-time PCR and immunohistochemistry at 24 hours after reperfusion.

Surgical procedures

Detailed methods have been described previously (Longa et al, 1989). Brie fl y, rats were anesthetized with 10% chloral hydrate (400 mg/kg intraperitoneally). A midline neck incision was made and the right common carotid, external carotid and internal carotid arteries were isolated. A 4-0 nylon monofilament (Ethicon, Somerville, NJ, USA) coated with silicon resin (Xantopren; Heraeus Kulzer, Germany) was inserted into the right internal carotid artery and advanced to occlude the middle cerebral artery. Regional cerebral blood fl ow was measured using a laser Doppler fl ow meter probe (Omega fl o, Omegawave Inc., Tokyo, Japan). After 90 minutes of occlusion, the fi lament was withdrawn to allow reperfusion. Rectal temperature was strictly maintained at 37.0 ± 0.5°C by a thermal blanket until the animal recovered from anesthesia.

Neurological function

Neurological de fi cit scores were measured before the animals were sacri fi ced based on the following graded scoring system (Hunter et al., 2000): 0, no de fi cit; 1, fl exion of contralateral torso and forelimb upon lifting of the whole animal by the tail; 2, circling to the contralateral side, when held by tail with feet on floor; 3, spontaneous circling to contralateral side; 4, no spontaneous motor activity.

Measurement of infarct size

After neurological de fi cit scores were determined, the rats were deeply anesthetized with 10% chloral hydrate (800 mg/kg intraperitoneally). The brain tissues were immediately removed and cut into 2 mm thick coronal sections. These sections were stained with 2% 2,3,5-triphenyltetrazolium chloride solution and then fixed in 4% paraformaldehyde. Each infarct area was measured using NIH Image analysis software version 1.61 (Media Cybernetics, Silver Spring, MD, USA) to calculate the infarct size.

Measurement of brain water content

Water on the surface of the brain sections was blotted with fi lter paper and the humid weight of the paper was measuredon an electronic balance. The sections were then grilled for 48 hours at 110°C in an electrothermostatic blast oven to obtain the dry weight. Brain water content was calculated by the formula: (humid weight — dry weight) / humid weight × 100%.

Detection of mRNA expression of Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-αin ischemic brain tissue by real-time reverse transcription-PCR (RT-PCR)

RT-PCR was performed to detect the mRNA levels of Tolllike receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-α. Total RNA was isolated from ischemic cerebral cortex using TRIzol reagent (Takara Bio, Shiga, Japan) in accordance with the manufacturer’s instructions. Complementary DNA (cDNA) was synthesized from 1 μg of total RNA using a high-capacity cDNA reverse-transcription kit (Takara Bio). Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-α were all analyzed in the same Micro-Amp optical 96-well plate, in triplicate, using a 7900HT RT-PCR System (Takara Bio), and β-actin served as an endogenous internal control for each sample. Comparative RT-PCR assays were performed for each sample in a fi nal reaction volume of 25 μL, containing 12.5 μL SYBR green fl uorescent dye (Takara Bio), 2 μL cDNA, and 50 pmol each of the forward and reverse primers (Shanghai Biosune Biotechnology Co., Ltd., Shanghai, China). The PCR primer sequences were designed according to the Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B, tumor necrosis factor-α and β-actin gene sequences reported in GenBank (http://www.ncbi.nlm.nih.gov/genbank) (Table 1). Amplification was carried out at 95°C for 1 minute, followed by 40 PCR cycles of 95°C for 10 seconds, 60°C for 40 seconds, 95°C for 15 seconds, 60°C for 30 seconds, 55°C for 15 seconds, and fi nally 95°C for 15 seconds. The comparative Ct method was used to determine the relative expression of target genes, where expression = 2?△△Ct, △△Ct=△Cttargetgene— △Ctcalibrator, and △Ct = Cttargetgene— Ctcontrolgene.

Detection of Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-αprotein expression in the peri-infarct area of ischemic cortex by immunohistochemistry

Sections were incubated in 3% H2O2to eliminate endogenous peroxidase activity. After rinsing with phosphate-buffered saline (PBS; 0.01 mol/L, pH 7.4), the sections were placed in citrate buffer (0.01 mol/L, pH 6.0) at 95—100°C for 15 minutes for antigen retrieval, and cooled to room temperature. After three rinses with PBS, the sections were blocked with 5% goat serum for 30 minutes, and were then incubated successively overnight at 4°C with primary rabbit anti-rat polyclonal antibodies (Toll-like receptor 4, 1:250; myeloid differentiation factor 88, 1:250; nuclear factor kappa B, 1:100; tumor necrosis factor-α, 1:200; all from Boster, Wuhan, Hubei Province, China). The sections were rinsed with PBS and incubated with biotinylated goat anti-rabbit IgG secondary antibody (1:150; Boster) at 37°C for 120 minutes. The sections were rinsed again with PBS and incubated with horseradish peroxidase-labeled streptavidin at 37°C for 30 minutes. Slices were then developed with 3,3′-diaminobenzidine, counterstained with hematoxylin, and then dehydrated and mounted. Three sections from each brain, 100 μm apart, were observed, and six fi elds of view (200×) were selected randomly in the peri-infarct area for immunopositive cell counting under a DP70 microscope (Olympus, Tokyo, Japan).

Statistical analysis

Data were expressed as the mean ± SD. Differences between groups were revealed by one-way analysis of variance and the Student-Newman-Keuls post-hoc test using SPSS 10.0 software (SPSS, Chicago, IL, USA). P ＜ 0.05 was considered statistically signi fi cant.

Results

Effects of puerarin on neurological function, infarct size and brain water content 24 hours after cerebral ischemia and reperfusion

Neurological function

Neurological funotion was significantly better in the puerarin treatment group than in the vehicle group 24 hours after reperfusion (P ＜ 0.05;Figure 1A).

Infarct size

Twenty-four hours after reperfusion, no infarction was observed in the sham surgery group, while extensive infarction developed in the striatum and cortex in vehicle and puerarin groups. Compared with the vehicle group, the infarct size was significantly smaller in the puerarin treatment group (P ＜0.05;Figure 1B and Figure 2).

Brain water content

Twenty-four hours after reperfusion, brain water content was signi fi cantly lower in the puerarin treatment group than in the vehicle control group (P ＜ 0.05;Figure 1C).

Effects of puerarin on the expression of Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-αmRNA in the peri-infarct area 24 hours after cerebral ischemia and reperfusion

RT-PCR revealed that Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-α mRNA expression was signi fi cantly higher in the vehicle group than in the sham surgery group (P ＜ 0.01), and lower in the puerarin treatment group than in the vehicle group (P ＜ 0.05;Figure 3).

Effects of puerarin on the expression of Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-αprotein in the peri-infarct area 24 hours after cerebral ischemia and reperfusion

Immunohistochemistry showed minimal expression of Tolllike receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-α protein in the shamsurgery group. Expression of all four proteins was notably increased in the vehicle and puerarin groups, but signi fi cantly less in the puerarin treatment group than in the vehicle control group (P ＜ 0.05;Figure 4).

Discussion

Huang et al. (2006) found that in fl ammatory cell adhesion molecules, chemokines and cytokines play a central role in cerebral ischemia/reperfusion injury in animal models of middle cerebral artery occlusion. Investigations into the pathophysiological mechanisms of cerebral ischemia/reperfusion injury are necessary to find new and more effective drugs for stroke. Puerarin, a major iso fl avonoid derived from the Chinese herb Radix puerariae, reduces cerebral ischemia/ reperfusion injury induced by middle cerebral artery occlusion in rats (Pan et al., 2005; Zhang et al., 2008), but the mechanism is unknown.

In the present study, we investigated the effects of puerarin on the expression of Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-α in the ischemic region after middle cerebral artery occlusion in rats. We found that its mechanism may involve inhibition of the Toll-like receptor 4-mediated and myeloid differentiation factor 88-dependent signaling pathway, which would in turn suppress the in fl ammatory reaction, improve neurological de fi cit levels, and reduce infarct size and cerebral edema.

Results from the present study con fi rmed that puerarin diminished Toll-like receptor 4 expression in brain tissue with ischemia/reperfusion injury. Toll-like receptors are a large family of transmembrane proteins, able to identify a number of microbial products and pathogen-associated molecular patterns. Upon activation, Toll-like receptors trigger inherent and adaptive immune responses through cytokines, interferons, chemokines, and cell surface receptor molecules (Longa et al., 1989; Frangogiannis et al., 1998; Minami et al., 2005, 2006; Frangogiannis, 2007). Several studies have indicated that Toll-like receptors play a key role in cerebral ischemia/ reperfusion injury (Arumugam et al., 2009; Hamanaka et al., 2011; Kong et al., 2011; Wang et al., 2011). Here, Toll-like receptor 4 expression was notably greater in the peri-infarct area, providing further evidence in support of its role in the pathophysiology of ischemia/reperfusion injury (Tang et al., 2007; Zhang et al., 2013). Activation of Toll-like receptors is involved in adverse reactions during cerebral ischemia (Yang et al., 2008; Hyakkoku et al., 2010). Toll-like receptor 4 activation can also lead to a decrease in nuclear factor kappa B and tumor necrosis factor-α expression, indicating that the activation of the Toll-like receptor 4-mediated myeloid differentiation factor 88-dependent signaling pathway is associated with an increased expression of nuclear factor kappa B and tumor necrosis factor-α after cerebral ischemia (Gosselin et al., 2008; Gao et al., 2009).

Toll-like receptor 4 can be activated by endogenous and exogenous factors after cerebral ischemia/reperfusion injury, triggering signal transduction pathways, activating and transcribing nuclear factor kappa B through the dependent or independent myeloid differentiation factor 88 pathways, and resulting in the expression of tumor necrosis factor-α, interleukin-1 and interleukin-6 that are associated with inflammatory responses (Yang et al., 2008; Arumugam et al., 2009; Backer et al., 2011). Studies addressing lipopolysaccharide-stimulated microglia con fi rmed that iso fl avones inhibited the expression of in fl ammation-related cytokines by blocking nuclear translocation of nuclear factor kappa B. Iso fl avones may also exert therapeutic effects in some neurodegenerative diseases and ischemic brain injury (Park et al., 2007; Singh et al., 2013; Jeong et al., 2014). The nuclear factor kappa B signaling pathway provides many possible targets for intervention during cerebral ischemia/reperfusion injury (Leeman et al., 2008). Inhibition of the in fl ammatory response in the early stage of ischemia/reperfusion injury is an attractive therapeutic strategy (Caso et al., 2007; Pradillo et al., 2009). The results of our study indicate that puerarin attenuates the transcription of nuclear factor kappa B through myeloid differentiation factor 88 dependent pathways, since the expression of both myeloid differentiation factor 88 and nuclear factor kappa B expression was reduced by puerin.

In summary, our study provides new evidence for the mechanism of the protective effect of puerarin on focal cerebral ischemia/reperfusion injury. The effect was associated with a lower expression of Toll-like receptor 4, myeloid differentiation factor 88, nuclear factor kappa B and tumor necrosis factor-α in the acute phase of cerebral ischemia/ reperfusion injury. An anti-inflammatory effect via inhibition of the Toll-like receptor 4-myeloid differentiation factor 88-nuclear factor kappa B pathway may underlie the neuroprotective effect of puerarin in cerebral ischemia/reperfusion injury.

Author contributions:Shen H and Zhou F designed the study. Wang L and Liu PP obtained the data. Hu WW and Zhu XD analyzed the data. Yao YY and Wang L wrote the report. Zhou F critically revised the report. All authors approved the final version of the paper.

Con fl icts of interest:None declared.

Aderem A, Ulevitch RJ (2000) Toll-like receptors in the induction of the innate immune response. Nature 406:782-787.

Akira S (2006) TLR signaling. Curr Top Microbiol Immunol 311:1-16.

Arumugam TV, Okun E, Tang SC, Thundyil J, Taylor SM, Woodruff TM (2009) Toll-like receptors in ischemia-reperfusion injury. Shock 32:4-16.

Baker RG, Hayden MS, Ghosh S (2011) NF-κB, inflammation, and metabolic disease. Cell Metab 13:11-22.

Burguete MC, Toregrosa G, Perez-Asensio FJ, Castello-Ruiz M, Salom JB, Gil JV, Alborch E (2006) Dietary phytoestrogens improve stroke outcome after transient focal cerebral ischemia in rats. Eur J Neurosci 23:703-710.

Cao CX, Yang QW, Ly FL, Cui J, Fu HB, Wang JZ (2006) Reduced cerebral ischemia- reperfusion injury in Toll-like receptor 4 de fi cient mice. Biochem Biophys Res Comm 353:509-514.

Caso JR, Pradillo JM, Hurtado O, Lorenzo P, Moro MA, Lizasoain I (2007) Toll-Like receptor 4 is involved in brain damage and in fl ammation after experimental stroke. Stroke 115:1599-1608.

Figure 1 Effects of puerarin on neurological de fi cit score, infarct size and brain water content 24 hours after cerebral ischemia and reperfusion.

Figure 2 Ischemic regions of representative rats from each group24 hours after reperfusion (2% 2,3,5-triphenyltetrazolium chloride staining).

Chang Y, Hsieh CY, Peng ZA, Yen TL, Hsiao G, Chou DS, Chen CM, Sheu JR (2009) Neuroprotective mechanisms of puerarin in middle cerebral artery occlusion-induced brain infarction in rats. J Biomed Sci 16:9.

Chen SQ, Lin JP, Wang SZ, Chen LC, Hong Y, Zhang KM (2013) Puerarin protects rat cervical intervertebral disc annulus fibrosus cells: An optimal concentration study. Zhongguo Zuzhi Gongcheng Yanjiu 17:1156-1161.

Danton GH, Dietrich WD (2003) In fl ammatory mechanisms after ischemia and stroke. J Neuropathol Exp Neurol 62:127-136.

Ding MP, Feng F, Hu HT (2007)Effects of puerarin on expression of nuclear factor kappaB after cerebral ischemia/reperfusion in rats. Zhongguo Zhong Yao Za Zhi 32:2515-2518.

Frangogiannis NG (2007) Chemokines in ischemia and reperfusion. Thromb Haemost 97:738-747.

Figure 3 Effects of puerarin on TLR4, MyD88, NF-κB and TNF-αmRNA expression in the peri-infarct area of rats at 24 hours after cerebral ischemia and reperfusion.

Frangogiannis NG, Youker KA, Rossen RD, Gwechenberger M, Lindsey MH, Mendoza LH, Michael LH, Ballantyne CM, Smith CW, Entman ML (1998) Cytokines and the microcirculation in ischemia and reperfusion. J Mol Cell Cardiol 30:2567-2576.

Gao Y, Fang X, Sun H, Wang Y, Yao LJ, Li JP, Tong Y, Zhang B (2009) Toll-like receptor 4-mediated myeloid differentiation factor 88-dependent signaling pathway is activated by cerebral ischemia-reperfusion in hippocampal CA1 region in mice. Biol Pharm Bull 32: 1665-1671.

Gosselin D, Rivest S (2008) MyD88 signaling in brain endothelial cells is essential for the neuronal activity and glucocorticoid release during systemic in fl ammation. Mol Psychiatry 13:480-497.

Hallenbeck JM (2002) The many faces of tumor necrosis factor in stroke. Nat Med 8:1363-1368.

Hamanaka J, Hara H (2011) Involvement of Toll-like receptors in ischemia-induced neuronal damage. Cent Nerv Syst Agents Med Chem 11:107-113.

Han RM, Tian YX, Becker EM, Andersen ML, Zhang JP, Skibsted LH (2007) Puerarin and conjugate bases as radical scavengers and antioxidants: molecular mechanism and synergism with β-carotene. J Agric Food Chem 55:2384-2391.

Figure 4 Effects of puerarin on the expression of TLR4, MyD88, NF-κB and TNF-αprotein in the peri-infarct area 24 hours after cerebral ischemia and reperfusion (immunohistochemical staining).

Hayden MS, Ghosh S (2004) Signaling to NF-kappaB. Genes Dev 18:2195-2224.

Hua F, Ma J, Ha T, Xia Y, Kelley J, Williams DL, Kao RL, Browder IW (2007) Activation of Toll-like receptor 4 signaling contributes to hippocampal neuronal death following global cerebral ischemia/reperfusion. J Neurochem 190:101-111.

Hua F, Ma J, Ha T, Kelley JL, Kao RL, Schweitzer JB, Kalbfleisch JH, Williams DL, Li C (2009) Differential roles of TLR2 and TLR4 in acute focal cerebral ischemia/reperfusion injury in mice. Brain Res 1262:100-108.

Huang J, Upadhyay UM, Tamargo RJ (2006) Inflammation in stroke and focal cerebral ischemia. Surg Neurol 66:232-245.

Hyakkoku K, Hamanaka.J, Tsuruma.K, Shimazawa M, Tanaka H, Uematsu S, Akira S, Inagaki N (2010) Toll-like recrptor 4 (TLR4), but not TLR3 or TLR9 knock-out mice have neuroprotective effects against focal cerebral ischemia. Neuroscience 171:258-267.

Ishizuka F, Shimazawa M, Inoue Y, Nakano Y, Ogishima H, Nakamura S, Tsuruma K, Tanaka H, Inagaki N, Hara H (2013) Toll-like receptor 4 mediates retinal ischemia/reperfusion injury through nuclear factor-κB and spleen tyrosine kinase activation. Invest Ophthalmol Vis Sci 54:5807-5816.

Janeway CA Jr, Medzhitov R (2002) Innate immune recognition Annu Rev Immunol 20:197-216.

Jeong JW, Lee HH, Han MH, Kim GY, Kim WJ, Choi YH (2014) Anti-in fl ammatory effects of genistein via suppression of the toll-like receptor 4-mediated signaling pathway in lipopolysaccharide-stimulated BV2 microglia. Chem Biol Interact 212:30-39.

Kaczorowski DJ, Tsung A, Billiar TR (2009) Innate immune mechanisms in ischemia/reperfusion. Front Biosci (Elite Ed) 1:91-98.

Kerfoot SM, Long.EM, Hickey MJ, Andonegui G, Lapointe BM, Zanardo RC, Bonder C, James WG (2004) TLR4 contributes to disease-inducing mechanisms resulting in central nervous system autoimmune disease. J Immunol 173:7070-7077.

Kong Y, Le Y (2011) Toll-like receptors in in fl ammation of the central nervous system. Int Immunopharmacol 11:1407-1414.

Kumar A, Takada Y, Boriek AM, Aggarwal BB (2004) Nuclear factor-κB: its role in health and disease. J Mol Med 82:434-448.

Lambertsen KL, Biber K, Finsen B (2012) In fl ammatory cytokines in experimental and human stroke. J Cereb Blood Flow Metab 27:1-22.

Leeman JR, Gilmore TD (2008) Alternative splicing in the NF-kappaB signaling pathway. Gene 423:97-107.

Lenardo MJ, Baltimore D (1989) NF-kappa B: a pleiotropic mediator of inducible and tissue-speci fi c gene control. Cell 58:227-229.

Liao SL, Chen WY, Raung SL, Kuo JS, Chen CJ (2001) Association of immune responses and ischemic brain infarction in rat. Neuroreport 12:1943-1947.

Lindsberg PJ, Grau AJ (2003) In fl ammation and infections as risk factors for ischemic stroke. Stroke 34:2518-2532.

Liu YS, Deng XB, Huo SF, Su L (2014) Activation of nuclear factor kappa B during heat stress-induced neuronal apoptosis. Zhongguo Zuzhi Gongcheng Yanjiu 18:1641-1646.

Longa EZ, Weinstein PR, Carlson S, Cummins R (1989) Reversible middle cerebral artery occlusion without craniectomy in rats. Stroke 20:84-91.

Minami M, Satoh M (2005) Role of chemokines in ischemic neuronal stress. Neuromolecular Med 7:149-155.

Minami M, Katayama T, Satoh M (2006) Brain cytokines and chemokines: roles in ischemic injury and pain. J Pharmacol Sci 100:461-470. Monje ML, Toda H, Palmer TD (2003) In fl ammatory blockade restores adult hippocampal neurogenesis. Science 302:1760-1765.

Pan HP, Yang JZ, Mo XL, Li LL, Huang ZL, Ye J, Huang J (2005) Protection of puerarin on the cerebral injury in the rats with acute local ischemia. Zhongguo Zhong Yao Za Zhi 30:457-459.

Park JS, Woo MS, Kim DH, Hyun JW, Kim WK, Lee JC, Kim HS (2007) Anti-inflammatory mechanisms of isoflavone metabolites in lipopolysaccharide-stimulated microglial cells. J Pharmacol Exp Ther 320:1237-1245.

Pradillo JM, Fernández-López D, García-Yébenes I, Sobrado M, Hurtado O, Moro MA, Lizasoain I ( 2009) Toll-like receptor 4 is involved in neuroprotection afforded by ischemic preconditioning. J Neurochem 109:287-294.

Ridder DA, Schwaninger M (2009) NF-kappa B signaling in cerebral ischemia. Neuroscience 158:995-1006.

Sang HF, Zhang YM, Xu LX, Wang Q, Ji GL, Wu MC (2001) Protective effect of puerarin on spinal cord injury resulting from ischemia and reperfusion in rabbits. Disi Junyi Daxue Xuebao 22:414-417.

Schneider A, Martin-Villalba A, Weih F, Vogel J, Wirth T, Schwaninger M (1999) NF-kappaB is activated and promotes cell death in focal cerebral ischemia. Nat Med 5:554-559.

Singh AK, Jiang Y, Gupta S, Younus M, Ramzan M (2013) Anti-in fl ammatory potency of nano-formulated puerarin and curcumin in rats subjected to the lipopolysaccharide- induced inflammation. J Med Food 16:899-911.

Takeda K (2005) Evolution and integration of innate immune recognition systems: the Toll-like receptors. J Endotoxin Res 11:51-55.

Tang SC, Arumugam TV, Xu X, Cheng A, Mughal MR, Jo DG, Lathia JD, Siler DA, Chigurupati S, Ouyang X, Magnus T, Camandola S, Mattson MP (2007) Pivotal role for neuronal toll-like receptors in ischemic brain injury and functional de fi cits. Proc Natl Acad Sci U S A 104:13798-13803.

Tian F, Xu LH, Zhao W, Tian LJ, Ji XL (2013) The neuroprotective mechanism of puerarin treatment of acute spinal cord injury in rats. Neurosci Lett 543:64-68.

Vila N, Castillo J, Davalos A, Chamorro A (2000) Proin fl ammatory cytokines and early neurological worsening in ischemic stroke. Stroke 31:2325-2329.

Wang C, Tang XL, Chen KM, Zhang L (2012) Effect of puerarin on proliferation and differentiation of osteoblasts in vitro. Zhongguo Zuzhi Gongcheng Yanjiu 16:6102-6106.

Wang L, Zhao A, Wang F, Chai Q, Chai X (1997) Protective effect of puerarin on acute cerebral ischemia in rats. Chin Material Med J 22:752-754.

Wang N, Zhang Y, Wu L, Wang Y, Cao Y, He L, Li X, Zhao J (2014) Puerarin protected the brain from cerebral ischemia injury via astrocyte apoptosis inhibition. Neuropharmacology 79:282-289.

Wang YC, Lin S, Yang QW (2011) Toll-like receptors in cerebral ischemic in fl ammatory injury. J Neuroin fl ammation. 8:134.

Wong CH, Crack PJ (2008) Modulation of neuro-inflammation and vascular response by oxidative stress following cerebral ischemia-reperfusion injury. Curr Med Chem 15:1-14.

Wu B, Liu M, Liu H, Li W, Tan S, Zhang S, Fang Y (2007) Meta-analysis of traditional chinese patent medicine for ischemic stroke. Stroke 38:1973-1979.

Xu X, Zhang S, Zhang L, Yan W, Zheng X (2005) The neuroprotection of puerarin against cerebral ischemia is associated with the prevention of apoptosis in rats. Planta Med 71:585-591.

Yang G, Ham I, Choi HY (2013) Anti-in fl ammatory effect of prunetin via the suppression of NF-κB pathway. Food Chem Toxicol 58:124-132.

Yang QW, Li JC, Lu FL, Wen AQ, Xiang J, Zhang LL, Huang ZY, Wang JZ (2008) Upregulated expression of toll-like receptor 4 in monocytes correlates with severity of acute cerebral infarction. J Cereb Blood Flow Metab 28:1588-1596.

Zhang J, Fu B, Zhang X, Chen L, Zhang L, Zhao X, Bai X, Zhu C, Cui L, Wang L (2013) Neuroprotective effect of bicyclol in rat ischemic stroke: down-regulates TLR4, TLR9, TRAF6, NF-κB, MMP-9 and up-regulates claudin-5 expression. Brain Res 1528:80-88.

Zhang YB, Du GY, Xiong YL, Zhao Y, Cui HF, Cao CY, Liu S (2008) Protective effects of 3’-methoxy-puerarin on rat brain suffering from ischemia. Zhongguo Zhong Yao Za Zhi 33:537-540.

Zhao T, Han J, Chen Y, Wan H, Bie X (2007) The mechanism of 3-methoxy puerarin on decreasing the cerebral ischemia-reperfusion injury in rats. Asia Pac J Clin Nutr 16 Suppl 1:302-304.

Zhou Y, Yao C, Gao F, Gao WW, Chen Y, Mou XH (2012) Enhancing angiogenesis by improving the expression of vascular endothelial growth factor and nuclear factor kappa B in surrounding tissues induced by astragalus polysaccharides collagen. Zhongguo Zuzhi Gongcheng Yanjiu 16:1184-1187.

Copyedited by Slone-Murphy J, Robens J, Wang J, Qiu Y, Li CH, Song LP, Zhao M

10.4103/1673-5374.147934

Yuanyuan Yao, M.D., Department of Anesthesiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China, yuanyuan58@126.com.

http://www.nrronline.org/

Accepted: 2014-08-18