Prostaglandin E receptors as targets for ischemic stroke: Novel evidence and molecular mechanisms of efficacy

Over the past two decades the interest has waned in therapeutically targeting cyclooxygenase-2 (COX-2) due to growing concerns over the potential cardiovascular and cerebrovascular toxicities of the long-term use of COX-2 inhibitors. Attention thus has recently been shifted downstream to the prostaglandin signaling pathways for new druggable anti-inflammatory targets aiming for higher therapeutic specificity. Prostaglandin E2 (PGE2) is robustly synthesized in the ischemic cortex by quickly induced COX-2 and microsomal prostaglandin E synthase1 (mPGES-1) following cerebral ischemia. The elevated PGE2, in turn, divergently regulates the excitotoxic injury and neuroinflammation by acting on four membrane-bound G protein-coupled receptors (GPCRs), namely, EP1EP4. Markedly, all four EP receptors have been implicated in the excitotoxicity-associated brain inflammation and injury in animal models of cerebral ischemia. However promising, these preclinical studies have not yet led to a clinical trial targeting any PGE2 receptor for ischemic stroke. The goal of this article is to review the recent progress in understanding the pathogenic roles of PGE2 in cerebral ischemia as well as to provide new mechanistic insights into the PGE2 signaling via these four GPCRs in neuronal excitotoxicity and inflammation. We also discuss the feasibility of targeting EP1-EP4 receptors as an emerging delayed treatment, together with the firstline reperfusion strategy, to manage acute ischemic stroke with potentially extended window as well as improved specificity.