Circadian Modulation of Neutrophil Function Determines Collateral Perfusion and Outcome After Ischemic Stroke

Stroke is a leading cause of mortality and disability, driven by complex and time-dependent mechanisms that aggravate ischemic damage. Among them, collateral perfusion determines the initial size of the ischemic core, the rate of its expansion, and the extent of the penumbra both at stroke onset and over time. Insufficiency of collaterals may occur due to genetic factors or other determinants, such as aging or cardiovascular risk factors, which reduce the number of collaterals or the diameter of those that remain. But aspects of less structural nature could also affect the effectiveness of these pathways by decreasing their patency. We hereby show that diurnal fluctuations in infarct volume in ischemic stroke mouse models are neutrophil phenotype-dependent, since differences in infarct volumes were abolished by depleting neutrophils or blocking their circadian clock, and linked to the collateral circulation: during the inactive phase of mice (daytime), collateral perfusion in the ipsilesional hemisphere was reduced, coinciding with an increase in intravascular neutrophil accumulation, suggestive of microvascular stalling. Single-cell transcriptomics, ex vivo functional assays and in vivo pharmacological and genetic strategies confirmed enhanced neutrophil extracellular traps (NETs) formation at this time. Importantly, in a cohort of human stroke patients, we identified diurnal oscillations in neutrophil and NET-related biomarkers, peaking during the human inactive phase (evening/night), and similarly associated with reduced collateral flow and poorer clinical outcomes. These findings underscore the critical role of neutrophils, their circadian dynamics and NET release in driving collateral insufficiency and ischemic brain damage, suggesting novel personalized therapeutic strategies based on circadian rhythms for the treatment of stroke.