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  3. Restoring cardiolipin homeostasis mitigates cerebral ischemia-reperfusion injury by suppressing ATG5-mediated neuronal autophagy-dependent ferroptosis

Restoring cardiolipin homeostasis mitigates cerebral ischemia-reperfusion injury by suppressing ATG5-mediated neuronal autophagy-dependent ferroptosis

  • J Adv Res. 2026 Mar 12:S2090-1232(26)00234-1. doi: 10.1016/j.jare.2026.03.014.
Weichen Dong 1,  Wenxin Zhang 2,  Li Huang 1,  Lulu Xiao 1,  Yuanfei Luo 3,  Linying Yuan 1,  Yike Jiang 1,  Anyu Liao 1,  Hongting Zhao 4,  Zhihui Liu 1,  Jia Wang 1,  Ying Zhao 1,  Yulong Cai 1,  Mengna Peng 1,  Dong Yang 1,  Yi Xie 5,  Kuanyu Li 6,  Wusheng Zhu 7
Affiliations

Affiliations

  • 1 State Key Laboratory of Pharmaceutical Biotechnology, Department of Neurology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China.
  • 2 State Key Laboratory of Pharmaceutical Biotechnology, Jiangsu Key Laboratory of Molecular Medicine, Medical School, Nanjing University, Nanjing 210093, China; Gulbenkian Institute for Molecular Medicine, Lisboa 2780-156, Portugal.
  • 3 Department of Neurology, Third Affiliated Hospital, Soochow University, Changzhou 213003, China.
  • 4 Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, China; the Chinese Clinical Medicine Innovation Center of Obstetrics, Gynecology, and Reproduction in Jiangsu Province, Nanjing 210029, China.
  • 5 Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China. Electronic address: [email protected].
  • 6 State Key Laboratory of Pharmaceutical Biotechnology, Jiangsu Key Laboratory of Molecular Medicine, Medical School, Nanjing University, Nanjing 210093, China. Electronic address: [email protected].
  • 7 State Key Laboratory of Pharmaceutical Biotechnology, Department of Neurology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China. Electronic address: [email protected].
PMID: 41831680 DOI: 10.1016/j.jare.2026.03.014
Abstract

Introduction: Cardiolipins (CLs) are mitochondria-specific Phospholipids critically involved in neurological disorders. However, their roles in cerebral ischemia/reperfusion (I/R) injury remains largely underexplored.

Objectives: This study aimed to characterize CL alterations following cerebral I/R injury, identify potential mechanisms underlying CL loss, and investigate the pathophysiological effects of these changes.

Methods: Ischemic stroke was modeled by using middle cerebral occlusion/reperfusion (MCAO/R) in mice and oxygen-glucose deprivation/reoxygenation (OGD/R) in vitro. CL alterations following cerebral I/R injury were evaluated through lipidomic analysis and fluorescent staining. The role of extracellular vesicles (EVs) in CL release was investigated. The effects of CL-targeting peptide SS-31 on CL release and homeostasis were assessed, and underlying mechanisms were explored by analyzing neuronal Autophagy and Ferroptosis. Plasma CL levels in stroke patients were also measured to elucidate clinical relevance.

Results: Significant CL depletion and acyl chain remodeling were observed in peri-infarct brain tissues. EV-mediated release was identified as one of the mechanisms of CL loss, and inhibiting EV release restored neuronal CL levels. SS-31 inhibits CL release, preserves CL content, and subsequently restores CL homeostasis. Restoring CL homeostasis attenuated cerebral I/R injury by suppressing neuronal Ferroptosis. Mechanistically, SS-31 downregulated autophagy-associated genes, with ATG5 identified as the crucial target. Activating Autophagy or overexpressing ATG5 reversed the protective effects of SS-31. Clinically, plasma CL levels in patients undergoing endovascular treatment correlated with 90-day functional outcomes.

Conclusion: Our findings establish CL preservation as a novel neuroprotective strategy, in which SS-31 mitigates I/R injury by restoring CL homeostasis and ameliorating ATG5-mediated autophagy-dependent neuronal Ferroptosis, offering a novel therapeutic avenue for stroke.

Keywords

Autophagy; Autophagy-related gene 5 (ATG5); Cardiolipin; Cerebral ischemia/reperfusion injury; Extracellular vesicle; Ferroptosis; SS-31.

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