• Users Online: 364
  • Home
  • Print this page
  • Email this page

 Table of Contents  
Year : 2023  |  Volume : 13  |  Issue : 1  |  Page : 7-9

Therapeutic applications of hydrogen sulfide and novel donors for cerebral ischemic stroke: a narrative review

Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China

Date of Submission02-Nov-2021
Date of Decision25-Jan-2022
Date of Acceptance02-Mar-2022
Date of Web Publication04-Aug-2022

Correspondence Address:
MD Qing Sun
Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province
MD Xiang Xu
Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2045-9912.350863

Rights and Permissions

Ischemic stroke happens when the blood supply to the brain is obstructed and it is associated with numerous complex mechanisms, such as activated apoptosis genes, oxidative stress and reaction of inflammation, which finally result in neurological deficits. Several gases have been proved to have neuroprotective roles, even the classic gases that are thought to be toxic such as hydrogen sulfide (H2S). H2S is the third identified endogenous gas signaling molecule following carbon monoxide and nitric oxide. H2S plays a significant role in stroke. Inhalation of H2S can attenuate cerebral infarct volume and promote neurological function in a rat model of middle cerebral artery occlusion to reduce ischemic stroke-induced injury in vivo and in vitro as a result. Therefore, H2S can be clinically used to reduce ischemic stroke-induced injury. This review introduces the toxic mechanisms and effects of H2S on cerebral ischemic stroke

Keywords: apoptosis; clinical application; donors; hydrogen sulfide; ischemic stroke; neuroinflammatory; oxidative stress; potential mechanism

How to cite this article:
Ding JS, Zhang Y, Wang TY, Li X, Ma C, Xu ZM, Sun Q, Xu X, Chen G. Therapeutic applications of hydrogen sulfide and novel donors for cerebral ischemic stroke: a narrative review. Med Gas Res 2023;13:7-9

How to cite this URL:
Ding JS, Zhang Y, Wang TY, Li X, Ma C, Xu ZM, Sun Q, Xu X, Chen G. Therapeutic applications of hydrogen sulfide and novel donors for cerebral ischemic stroke: a narrative review. Med Gas Res [serial online] 2023 [cited 2023 Mar 31];13:7-9. Available from: https://www.medgasres.com/text.asp?2023/13/1/7/350863

Jia-Sheng Ding, Yan Zhang
Both authors contributed equally to this work.

  Introduction Top

Ischemic stroke is defined as a precipitate loss of blood circulation in a part of the brain which leads to neurological deficits and cognitive decline.[1],[2] Thrombotic or embolic occlusion of cerebral arteries causes acute ischemic stroke.[3],[4] Males aged over 40 years old have great chance to suffer from ischemic stroke. What’s more, ischemic stroke can result in high morbidity, mortality and disability rates and may cause serious social and economic burdens.[5] Ischemia/reperfusion (I/R) injury causes severe damage to most organs and may occur in a variety of tissues including the brain, kidney, heart, and liver.[6],[7] Reactive oxygen species (ROS), as one of the main hazards, is excessively generated after I/R injury, leading to severe internal tissue damage, and further induces cell damage through reactions of inflammation.[8] Numerous studies have been conducted to improve the prognosis of stroke and many therapies have been discovered and applied.[9]

Hydrogen sulfide (H2S) is garnering increasing attention for its neuroprotective function.[10],[11] H2S is a small gaseous compound that acts as a gas transmitter along with carbon monoxide and nitric oxide.[12] It influences physiological and pathological processes throughout the body. However, increasing studies have shown that H2S has anti-inflammatory, anti-oxidative, and protective effects on neurological diseases. Sodium hydrosulfide (NaHS) as an H2S donor can protect the nerve system after I/R based on the data from in vitro studies and animal experiments.[13],[14] In recent years, other H2S donors have also been proved to have the neuroprotective activity to ischemic stroke. A great concern has been concentrated on inorganic H2S donors such as NaHS, which may generate H2S instantaneously at high concentrations and cause neurotoxic effects.[15],[16] Hence, we should pay attention to its beneficial effects that could address clinical problems of neuronal death caused by ischemia stroke. To explore the feasibility of H2S for clinical treatment, we analyze relevant experimental and clinical studies in this review and discuss the effects of H2S on ischemic stroke injury and possible neuroprotective mechanisms.

  Experimental Studies of Hydrogen Sulfide Donors in Ischemic Stroke Top

Before clinical applications, numerous animal experiments have been carried on. Animal models of ischemic stroke have been successfully established to explore the role of H2S in ischemic stroke.[16] It is impractical to inhale the gas directly due to its toxicity. Therefore, other reagents have been used in animals to simulate the effects of H2S. For example, NaHS which can form HS to react with H+ to form H2S is commonly used in experiments as a donor of H2S to explore the potential physiologic functions of H2S.[17] Inorganic H2S donors such as NaHS have been paid great attention which may generate H2S instantaneously at high concentrations and cause neurotoxic effects. Therefore, it is needed to develop quantitative and durable H2S release agents to maintain a defined concentration range of H2S. For example, 8e, as an H2S releasing derivative of 3-n-butylphthalide, reduced neural apoptosis, focal infarction, cerebral edema and sensorimotor deficits 72 hours after transient occlusion of middle cerebral artery significantly.[18] GYY4137 is also a new drug that can slowly release low concentrations of H2S in water for several days at physiological pH and temperature.[16] AP39 (50 nmol/kg), a H2S delivery molecule that can release slowly and targeted at mitochondria, reveals its neuroprotective activity and may reduce infarct volume and neurological deficits in the experimental AP39 groups.[15] These agents are applied to the model of ischemic stroke to explore the potential mechanisms of H2S. By comprehensive analysis of these experiments, we found that H2S plays a protective or deleterious role in the ischemic brain depending on its concentration, H2S is deleterious at a high concentration and protective at a low concentration. In some experiments, exogenously administered H2S in the form of NaHS at 180 mmol/kg but not at 90 mmol/kg increased infarct volume in permanent middle cerebral artery occlusion rats. N-methyl-D-aspartate receptor antagonist could attenuate this increase. Importantly, administration of cystathionine β-synthase inhibitors contributed to the reduction of infarct volume, suggesting that the production of endogenous H2S help ameliorate ischemic injuries.[19] Wen et al.[20] also reported that after 1 × 10–5 – 1 × 10–7 mol/kg NaHS supplements, H2S could help upregulate cerebral vascular function in terms of contraction and dilation which may depend on endothelium cells via activating potassium channel. H2S could therefore play an important role in the protection of cerebral I/R injury. In this review, the major mechanism and potential role of H2S in the treatment of ischemic stroke are discussed.

  Mechanisms of Hydrogen Sulfide in Ischemic Stroke Top

H2S plays a protective role via several mechanisms such as inhibiting oxidative stress, inflammation, endoplasmic reticulum stress, cell death and apoptosis. Here, we describe the mechanisms of H2S in ischemic stroke briefly [Figure 1] and [Additional Table 1 [Additional file 1]]).
Figure 1: Therapeutic applications of hydrogen for cerebral ischemic stroke.
Note: H2S: Hydrogen sulfide; ROS: reactive oxygen species.

Click here to view

Inhibition of autophagic activity

Exogenous H2S suppressed the elevation of microtubule-associated protein light chain 3-II and the decrease of p62, but had no notable effect on Beclin-1 complex of cerebral I/R injury model mice, which indicated that exogenous H2S decreased autophagosome accumulation to inhibit autophagy.[21] Jiang et al.[22] reported that H2S can attenuate brain injury by inhibiting the autophagic activity of cells. They built a middle cerebral artery occlusion model in vitro by oxygen-glucose deprivation/reoxygenation in PC12 cells and finally proved that NaHS treatment can alleviate injury in cells and inhibit autophagy overactivated by oxygen-glucose deprivation/reoxygenation in PC12 cells. Furthermore, the accumulation of autophagic vacuoles in mouse brain after I/R injury can be decreased by exogenous H2S.[23]

Anti-oxidative stress

Oxidative stress is a significant mechanism during the process of cerebral I/R injury. Oxidative stress can lead ROS accumulation and excessive ROS will damage neurons. Oxidative stress can activated Mitogen-activated protein kinase (MAPK) pathway and H2S may function as a neuroprotector by protecting against neuronal damage caused by oxidative stress biologically.[24] Exogenous H2S can inhibit p38MAPK and extracellular-regulated kinase 3 signaling pathway and regulate MAPK signaling pathway to protect neurons against injury from oxidative stress.[16],[25] Thus, it indicated that exogenous H2S provides a protective effect against oxygen-glucose deprivation/reoxygenation-induced injury by enhancing the activation of the ERK3, p38MAPK and nuclear factor-erythroid factor 2-related factor 2 mRNA.

Regulation of cerebral blood flow

H2S can upregulate the contraction and dilation function of cerebral vessels to change its blood flow partially via activating potassium channel. Phosphatidylinositol bisphosphate can activate ion channels directly, which potassium channels are also involoved. H2S can regulate potassium channel activity by altering channel-phosphatidylinositol bisphosphate interaction.[18] Shi et al.[26] reported that cerebral blood flow increases while the resistance of cerebral vessels, blood viscosity, and thrombogenesis decrease after treatment with NaHS. NaHS can also promote angiogenesis in the peri-infarct area after ischemic stroke, possibly through augmenting AKT and ERK phosphorylation and increasing angiopoietin-1 and vascular endothelial growth factor expression.[27] These results indicated that H2S performs its protective effect on ischemic stroke by improving the endothelium-dependent function of cerebral vessels in terms of contraction and dilation and promoting angiogenesis.


The nuclear factor kappa B (NF-κB) signaling pathway can be activated by ROS produced by oxidative stress within the cell, where NF-KB production can lead to increased levels of cytokines such as interleukin-6 and interleukin-1β to trigger inflammation. The anti-inflammatory effect of H2S can be mediated by inhibiting NF-κB.[28],[29] SB203580, a kind of p38MAPK inhibitor, significantly attenuates lipopolysaccharide-induced tumor necrosis factor-alpha secretion, another inflammatory indicator. H2S can play the same role as SB203580.[13] Hu et al.[13] confirmed that H2S is able to reduce inflammation by suppressing nitric oxide synthase and p38MAPK signaling pathways.


Accumulating evidence points out that H2S may play its role in anti-apoptosis via multiple apoptotic pathways. H2S can inhibit ROS-mediated caspase-3 signaling pathway via the calcium pathway and promote the nuclear translocation of NF-κB that mediates apoptosis pathways.[30],[31] In addition, exogenous H2S such as GYY4137 can inhibit p38MAPK and ERK1/2 pathways and regulate MAPK signaling pathway against neuronal injury from oxidative stress.[16] By regulating p38MAPK, ERK1/2 and c-Jun N-terminal kinase signaling pathways can inhibit apoptosis and protect neurons.[16]

Additional mechanism

H2S preconditioning could protect mice against cerebral I/R injury through activating heat shock protein-70 and phosphoinositide 3-kinase/Akt/nuclear factor-erythroid factor 2-related factor-2 pathway.[18] In addition, inhalation of H2S can activate protein kinase C and then downregulate the expression of aquaporin-4 to exert its protective effects.[14]

  Clinical Applications Top

The current study on H2S is still in the experimental stage and no clinical application has been reported. More clinical trials are needed to explore the value of H2S.

  Limitations Top

Most studies focused on the protective effects of H2S. However, they ignored the long-term protective effects of H2S. Therefore, it is important for us to investigate the effects of H2S on long-term stroke. Inorganic H2S donors may generate H2S instantaneously at a high concentration and may thus result in a neurotoxic effect. Therefore, new H2S donors for the quantitative and persistent release of H2S are needed, to ensure their safety in the treatment of cerebral ischemic stroke.

  Conclusions Top

H2S may exert a protective role in cerebral ischemic stroke. The role of H2S is somewhat inconsistent with those mentioned above that may depend on its concentration. More studies are needed to explore the possible role and mechanisms of H2S in neurofunctional protection and to explore how to optimize the use of this gas in ischemic stroke treatment. Finally, we confirm that H2S will blaze a new trail in the treatment of cerebral ischemic stroke.

Author contributions

Manuscript writing: DJS; manuscript revision: ZY; manuscript drafting: WTY and LX. All authors read and approved the final version of the manuscript for publication.

Conflicts of interest

The authors declare that they have no competing interests.

Editor note: GC is an Editorial Board member of Medical Gas Research. He was blinded from reviewing or making decisions on the manuscript. The article was subject to the journal’s standard procedures, with peer review handled independently of this Editorial Board member and his research group.

Availability of data and materials

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Open access statement

This is an open access journal, and articles are distributed under the terms of the Creative Commons AttributionNonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Additional file

Additional Table 1: Experimental studies of hydrogen sulfide in ischemic stroke of recent years (until 2021).

  References Top

Wang Y, Luo Y, Yao Y, et al. Silencing the lncRNA Maclpil in pro-inflammatory macrophages attenuates acute experimental ischemic stroke via LCP1 in mice. J Cereb Blood Flow Metab. 2020;40:747-759.  Back to cited text no. 1
Wu L, Zhang D, Chen J, et al. Long-term outcome of endovascular therapy for acute basilar artery occlusion. J Cereb Blood Flow Metab. 2021;41:1210-1218.  Back to cited text no. 2
Tseng N, Lambie SC, Huynh CQ, et al. Mitochondrial transfer from mesenchymal stem cells improves neuronal metabolism after oxidant injury in vitro: The role of Miro1. J Cereb Blood Flow Metab. 2021;41:761-770.  Back to cited text no. 3
Ye F, Garton HJL, Hua Y, Keep RF, Xi G. The role of thrombin in brain injury after hemorrhagic and ischemic stroke. Transl Stroke Res. 2021;12:496-511.  Back to cited text no. 4
Simpkins AN, Janowski M, Oz HS, et al. Biomarker application for precision medicine in stroke. Transl Stroke Res. 2020;11:615-627.  Back to cited text no. 5
Muthusamy A, Lin CM, Shanmugam S, Lindner HM, Abcouwer SF, Antonetti DA. Ischemia-reperfusion injury induces occludin phosphorylation/ubiquitination and retinal vascular permeability in a VEGFR-2-dependent manner. J Cereb Blood Flow Metab. 2014;34:522-531.  Back to cited text no. 6
Leigh R, Knutsson L, Zhou J, van Zijl PC. Imaging the physiological evolution of the ischemic penumbra in acute ischemic stroke. J Cereb Blood Flow Metab. 2018;38:1500-1516.  Back to cited text no. 7
Zhang H, Pan Q, Xie Z, et al. Implication of MicroRNA503 in brain endothelial cell function and ischemic stroke. Transl Stroke Res. 2020;11:1148-1164.  Back to cited text no. 8
Peterson TC, Lechtenberg KJ, Piening BD, et al. Obesity drives delayed infarct expansion, inflammation, and distinct gene networks in a mouse stroke model. Transl Stroke Res. 2021;12:331-346.  Back to cited text no. 9
Deng J, Lei C, Chen Y, et al. Neuroprotective gases--fantasy or reality for clinical use? Prog Neurobiol. 2014;115:210-245.  Back to cited text no. 10
Zhang ML, Peng W, Ni JQ, Chen G. Recent advances in the protective role of hydrogen sulfide in myocardial ischemia/reperfusion injury: a narrative review. Med Gas Res. 2021;11:83-87.  Back to cited text no. 11
Mukherjee S, Corpas FJ. Crosstalk among hydrogen sulfide (H(2)S), nitric oxide (NO) and carbon monoxide (CO) in root-system development and its rhizosphere interactions: A gaseous interactome. Plant Physiol Biochem. 2020;155:800-814.  Back to cited text no. 12
Hu LF, Wong PT, Moore PK, Bian JS. Hydrogen sulfide attenuates lipopolysaccharide-induced inflammation by inhibition of p38 mitogen-activated protein kinase in microglia. J Neurochem. 2007;100:1121-1128.  Back to cited text no. 13
Wei X, Zhang B, Cheng L, et al. Hydrogen sulfide induces neuroprotection against experimental stroke in rats by down-regulation of AQP4 via activating PKC. Brain Res. 2015;1622:292-299.  Back to cited text no. 14
Pomierny B, Krzyżanowska W, Jurczyk J, et al. The slow-releasing and mitochondria-targeted hydrogen sulfide (H(2)S) delivery molecule AP39 induces brain tolerance to ischemia. Int J Mol Sci. 2021;22:7816.  Back to cited text no. 15
Han X, Mao Z, Wang S, et al. GYY4137 protects against MCAO via p38 MAPK mediated anti-apoptotic signaling pathways in rats. Brain Res Bull. 2020;158:59-65.  Back to cited text no. 16
Farrugia G, Szurszewski JH. Carbon monoxide, hydrogen sulfide, and nitric oxide as signaling molecules in the gastrointestinal tract. Gastroenterology. 2014;147:303-313.  Back to cited text no. 17
Wang L, Wang X, Li T, Zhang Y, Ji H. 8e protects against acute cerebral ischemia by inhibition of PI3Kγ-mediated superoxide generation in microglia. Molecules. 2018;23:2828.  Back to cited text no. 18
Qu K, Chen CP, Halliwell B, Moore PK, Wong PT. Hydrogen sulfide is a mediator of cerebral ischemic damage. Stroke. 2006;37:889-893.  Back to cited text no. 19
Wen JY, Wang M, Li YN, Jiang HH, Sun XJ, Chen ZW. Vascular protection of hydrogen sulfide on cerebral ischemia/reperfusion injury in rats. Front Neurol. 2018;9:779.  Back to cited text no. 20
Shui M, Liu X, Zhu Y, Wang Y. Exogenous hydrogen sulfide attenuates cerebral ischemia-reperfusion injury by inhibiting autophagy in mice. Can J Physiol Pharmacol. 2016;94:1187-1192.  Back to cited text no. 21
Jiang WW, Huang BS, Han Y, Deng LH, Wu LX. Sodium hydrosulfide attenuates cerebral ischemia/reperfusion injury by suppressing overactivated autophagy in rats. FEBS Open Bio. 2017;7:1686-1695.  Back to cited text no. 22
Zhu Y, Shui M, Liu X, Hu W, Wang Y. Increased autophagic degradation contributes to the neuroprotection of hydrogen sulfide against cerebral ischemia/reperfusion injury. Metab Brain Dis. 2017;32:1449-1458.  Back to cited text no. 23
Son Y, Cheong YK, Kim NH, Chung HT, Kang DG, Pae HO. Mitogen-activated protein kinases and reactive oxygen species: how can ROS activate MAPK pathways? J Signal Transduct. 2011;2011:792639.  Back to cited text no. 24
Xin L, Junhua W, Long L, Jun Y, Yang X. Exogenous hydrogen sulfide protects SH-SY5Y cells from OGD/R induced injury. Curr Mol Med. 2017;17:563-567.  Back to cited text no. 25
Shi HQ, Zhang Y, Cheng MH, et al. Sodium sulfide, a hydrogen sulfide-releasing molecule, attenuates acute cerebral ischemia in rats. CNS Neurosci Ther. 2016;22:625-632.  Back to cited text no. 26
Jia J, Li J, Cheng J. H(2)S-based therapies for ischaemic stroke: opportunities and challenges. Stroke Vasc Neurol. 2019;4:63-66.  Back to cited text no. 27
Seifert HA, Pennypacker KR. Molecular and cellular immune responses to ischemic brain injury. Transl Stroke Res. 2014;5:543-553.  Back to cited text no. 28
Tao L, Yu Q, Zhao P, et al. Preconditioning with hydrogen sulfide ameliorates cerebral ischemia/reperfusion injury in a mouse model of transient middle cerebral artery occlusion. Chem Biol Interact. 2019;310:108738.  Back to cited text no. 29
Sen N, Paul BD, Gadalla MM, et al. Hydrogen sulfide-linked sulfhydration of NF-κB mediates its antiapoptotic actions. Mol Cell. 2012;45:13-24.  Back to cited text no. 30
Liu X, Zhao S, Liu F, et al. Remote ischemic postconditioning alleviates cerebral ischemic injury by attenuating endoplasmic reticulum stress-mediated apoptosis. Transl Stroke Res. 2014;5:692-700.  Back to cited text no. 31


  [Figure 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Experimental Stu...
Mechanisms of Hy...
Clinical Applica...
Article Figures

 Article Access Statistics
    PDF Downloaded552    
    Comments [Add]    

Recommend this journal