51
|
Nishinaka T, Yamazaki Y, Niwa A, Wake H, Mori S, Yoshino T, Nishibori M, Takahashi H. Alterations of lymphocyte count and platelet volume precede cerebrovascular lesions in stroke-prone spontaneously hypertensive rats. Biomarkers 2020; 25:305-313. [PMID: 32285702 DOI: 10.1080/1354750x.2020.1750703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Cerebral small vessel disease (CSVD) is associated with future stroke. Although pathological alteration in small vessels of patients with CSVD can be detected by neuroimaging, diagnosis of CSVD is delayed because it is an asymptomatic disease. The stroke-prone spontaneously hypertensive rat (SHRSP) show similar pathological features to human CSVD and develop stroke-related symptoms with advancing age.Objective: We investigated the time course of haematological parameters in Wistar rats and SHRSP.Material and Methods: Blood cells were analysed using an automated haematological analyser.Results: SHRSP develop stroke-related symptoms including onset of neurological symptoms, decreased body weight and blood brain barrier leakage between 12 and 14 weeks of age. Lymphocyte counts were gradually decreased at 3 weeks before development of stoke-related symptoms and then were further decreased after the development of stroke-related symptoms. The both mean platelet volume and large platelet ratio gradually increased at 3 weeks before the development of stoke-related symptoms. However, although SHRSP showed more microcytic red cells than Wistar rats, the trajectories of change in erythrocyte-related parameters were similar between Wistar rats and SHRSP.Conclusion: Our pilot study suggests that alterations of lymphocyte count and platelet volume predictive indicators for asymptomatic CSVD and symptomatic stroke in SHRSP.
Collapse
Affiliation(s)
- Takashi Nishinaka
- Department of Pharmacology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Yui Yamazaki
- Department of Pharmacology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Atsuko Niwa
- Department of Pharmacology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Hidenori Wake
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Shuji Mori
- Department of Pharmacology, School of Pharmacy, Shujitsu University, Okayama, Japan
| | - Tadashi Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Masahiro Nishibori
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hideo Takahashi
- Department of Pharmacology, Faculty of Medicine, Kindai University, Osaka, Japan
| |
Collapse
|
52
|
Zera KA, Buckwalter MS. The Local and Peripheral Immune Responses to Stroke: Implications for Therapeutic Development. Neurotherapeutics 2020; 17:414-435. [PMID: 32193840 PMCID: PMC7283378 DOI: 10.1007/s13311-020-00844-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The immune response to stroke is an exciting target for future stroke therapies. Stroke is a leading cause of morbidity and mortality worldwide, and clot removal (mechanical or pharmacological) to achieve tissue reperfusion is the only therapy currently approved for patient use. Due to a short therapeutic window and incomplete effectiveness, however, many patients are left with infarcted tissue that stimulates inflammation. Although this is critical to promote repair, it can also damage surrounding healthy brain tissue. In addition, acute immunodepression and subsequent infections are common and are associated with worse patient outcomes. Thus, the acute immune response is a major focus of researchers attempting to identify ways to amplify its benefits and suppress its negative effects to improve short-term recovery of patients. Here we review what is known about this powerful process. This includes the role of brain resident cells such as microglia, peripherally activated cells such as macrophages and neutrophils, and activated endothelium. The role of systemic immune activation and subsequent immunodepression in the days after stroke is also discussed, as is the chronic immune responses and its effects on cognitive function. The biphasic role of inflammation, as well as complex timelines of cell production, differentiation, and trafficking, suggests that the relationship between the acute and chronic phases of stroke recovery is complex. Gaining a more complete understanding of this intricate process by which inflammation is initiated, propagated, and terminated may potentially lead to therapeutics that can treat a larger population of stroke patients than what is currently available. The immune response plays a critical role in patient recovery in both the acute and chronic phases after stroke. In patients, the immune response can be beneficial by promoting repair and recovery, and also detrimental by propagating a pro-inflammatory microenvironment. Thus, it is critical to understand the mechanisms of immune activation following stroke in order to successfully design therapeutics.
Collapse
Affiliation(s)
- Kristy A Zera
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA.
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA.
- Department of Neurosurgery, Stanford Univeristy School of Medicine, Stanford, CA, USA.
| |
Collapse
|
53
|
Infections causing stroke or stroke-like syndromes. Infection 2020; 48:323-332. [PMID: 32239441 DOI: 10.1007/s15010-020-01415-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/20/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Stroke has relevant morbidity and mortality despite appropriate treatments and early diagnosis. Beside common risk factors such as diabetes and atrial fibrillation, infections can be involved in stroke pathogenesis, probably causing a systemic release of cytokines and other inflammatory mediators, triggering a latent pro-thrombotic state or damaging the vascular endothelium. In other cases, infections can occur as stroke-like syndromes, requiring a high grade of suspicion to avoid a delay in establishing a correct diagnosis. RESULTS Treatment of stroke or stroke-like syndromes of infectious origin can be difficult. When a previous infective event triggers stroke, Alteplase administration can be associated with a higher incidence of bleeding and the extension of the ischaemic area can be major than expected. On the other hand, when stroke is part of some infectious diseases' presentation as in endocarditis, bacterial or tuberculous meningitis and meningo-vascular syphilis, a correct diagnosis can be difficult. The management of these stroke-like syndromes is not standardised because common treatments proven to be effective for patients with stroke of vascular origin can worsen the prognosis, as it can be demonstrated after to be incorrect Alteplase administration to patients with endocarditis with septic embolism to the brain is associated with an increase of the risk of haemorrhage. CONCLUSIONS Stroke or stroke-like syndrome of infectious origin can be observed in an important proportion of case presenting with sensory-motor deficit of unknown origin; their accurate diagnosis has a considerable impact in terms of treatment choices and outcome.
Collapse
|
54
|
Ying A, Cheng Y, Lin Y, Yu J, Wu X, Lin Y. Dynamic increase in neutrophil levels predicts parenchymal hemorrhage and function outcome of ischemic stroke with r-tPA thrombolysis. Neurol Sci 2020; 41:2215-2223. [PMID: 32180156 DOI: 10.1007/s10072-020-04324-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The higher level of neutrophil on admission has been reported to predict worse 3-month outcomes in ischemic stroke patients. Our study was to explore the dynamic changes of neutrophil and lymphocyte after r-tPA thrombolysis of ischemic stroke and the relationship with parenchymal hemorrhage (PH) and 3-month function outcome. METHODS A total of 208 acute ischemic stroke (AIS) patients with intravenous thrombolysis were included and then received 3-month follow-up in the present study. Blood samples for neutrophil and lymphocyte counts were obtained on admission, at 24 h and at 7 days after r-tPA infusion. The associations of increase in neutrophil, lymphocyte, and neutrophil to lymphocyte ratio (NLR) with PH or 3-month poor outcome were examined by logistic regression. RESULTS Increasing trends in the neutrophil and NLR were observed in AIS patients after r-tPA treatment. Increased level of neutrophil at 24 h after r-tPA infusion but not that on admission was associated with PH (OR = 2.86, P = 0.029) and 3-month poorer functional outcomes (OR = 2.67, P = 0.009). Moreover, patients were divided into four groups according to the percent change in neutrophil within 24 h following r-tPA treatment, and we found that there was a trend of incremental OR when compared higher increase group with lower ones. CONCLUSIONS Dynamic increase in neutrophil and NLR after stroke may predict PH and 3-month poor outcome in AIS patients receiving r-tPA treatment. Therefore, neutrophil and NLR may serve as activity markers for PH and 3-month poor prognosis in AIS patients with intravenous thrombolysis.
Collapse
Affiliation(s)
- AnNa Ying
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - YaNi Cheng
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - YanYan Lin
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - JunRu Yu
- Department of Neurology, Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - XiaoYun Wu
- Department of Rehabilitation, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - YuanShao Lin
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
| |
Collapse
|
55
|
van Lieshout JH, Marbacher S, Muhammad S, Boogaarts HD, Bartels RHMA, Dibué M, Steiger HJ, Hänggi D, Kamp MA. Proposed Definition of Experimental Secondary Ischemia for Mouse Subarachnoid Hemorrhage. Transl Stroke Res 2020; 11:1165-1170. [PMID: 32152960 PMCID: PMC7496000 DOI: 10.1007/s12975-020-00796-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/17/2020] [Accepted: 02/21/2020] [Indexed: 01/01/2023]
Abstract
Inconsistency in outcome parameters for delayed cerebral ischemia (DCI) makes it difficult to compare results between mouse studies, in the same way inconsistency in outcome parameters in human studies has for long obstructed adequate comparison. The absence of an established definition may in part be responsible for the failed translational results. The present article proposes a standardized definition for DCI in experimental mouse models, which can be used as outcome measure in future animal studies. We used a consensus-building approach to propose a definition for "experimental secondary ischemia" (ESI) in experimental mouse subarachnoid hemorrhage that can be used as an outcome measure in preclinical studies. We propose that the outcome measure should be as follows: occurrence of focal neurological impairment or a general neurological impairment compared with a control group and that neurological impairment should occur secondarily following subarachnoid hemorrhage (SAH) induction compared with an initial assessment following SAH induction. ESI should not be used if the condition can be explained by general anesthesia or if other means of assessments sufficiently explain function impairment. If neurological impairment cannot reliably be evaluated, due to scientific setup. Verification of a significant secondary impairment of the cerebral perfusion compared with a control group is mandatory. This requires longitudinal examination in the same animal. The primary aim is that ESI should be distinguished from intervention-related ischemia or neurological deficits, in order establish a uniform definition for experimental SAH in mice that is in alignment with outcome measures in human studies.
Collapse
Affiliation(s)
- Jasper Hans van Lieshout
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, D-40225, Düsseldorf, Germany. .,Department of Neurosurgery, Radboudumc Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands.
| | - Serge Marbacher
- Department of Neurosurgery c/o Neuro Research Office, Kantonsspital Aarau, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, D-40225, Düsseldorf, Germany
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboudumc Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands
| | - Ronald H M A Bartels
- Department of Neurosurgery, Radboudumc Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands
| | - Maxine Dibué
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, D-40225, Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, D-40225, Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, D-40225, Düsseldorf, Germany
| | - Marcel A Kamp
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, D-40225, Düsseldorf, Germany
| |
Collapse
|
56
|
Fan H, Tang X, Song Y, Liu P, Chen Y. Influence of COVID-19 on Cerebrovascular Disease and its Possible Mechanism. Neuropsychiatr Dis Treat 2020; 16:1359-1367. [PMID: 32547039 PMCID: PMC7266513 DOI: 10.2147/ndt.s251173] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The global spread of COVID-19 has caused a substantial societal burden and become a major global public health issue. The COVID-19 elderly population with hypertension, diabetes, cardiovascular, and cerebrovascular diseases are at risk. Mortality rates are highest in these individuals if infected with COVID-19. Although the lungs are the main organs involved in acute respiratory distress syndrome caused by COVID-19 infection, COVID-19 triggers inflammatory and immune mechanisms, inducing a "cytokine storm" that aggravates disease progression and may lead to death. Presently, effective drugs are lacking, although current studies have confirmed that drugs with therapeutic potential include redaciclovir, lopinavir/ritonavir combined with interferon-β, convalescent plasma, and monoclonal antibodies. Currently, the most reasonable and effective way to prevent COVID-19 is to control the source of infection, terminate routes of transmission, and protect susceptible populations. With the rise of COVID-19 in China and worldwide, further prevention, diagnosis, and treatment measures are a critical unmet need. Cerebrovascular disease has high incidence, disability rate, and fatality rate. COVID-19 patient outcomes may also be complicated with acute stroke. This paper summarizes the influence of COVID-19 on cerebrovascular disease and discusses possible pathophysiological mechanisms to provide new angles for the prevention and diagnosis of this disease.
Collapse
Affiliation(s)
- Hongyang Fan
- Clinical Medical College, Yangzhou University, Yangzhou City, Jiangsu Province, People's Republic of China.,Department of Neurology, Northern Jiangsu Province Hospital, Yangzhou City, Jiangsu Province, People's Republic of China
| | - Xiaojia Tang
- Department of Neurology, Northern Jiangsu Province Hospital, Yangzhou City, Jiangsu Province, People's Republic of China.,Department of Neurology, Clinical Medical College of Yangzhou, Dalian Medical University, Yangzhou City, Jiangsu Province, People's Republic of China
| | - Yuxia Song
- Department of Neurology, Northern Jiangsu Province Hospital, Yangzhou City, Jiangsu Province, People's Republic of China.,Department of Neurology, Clinical Medical College of Yangzhou, Dalian Medical University, Yangzhou City, Jiangsu Province, People's Republic of China
| | - Peipei Liu
- Clinical Medical College, Yangzhou University, Yangzhou City, Jiangsu Province, People's Republic of China.,Department of Neurology, Northern Jiangsu Province Hospital, Yangzhou City, Jiangsu Province, People's Republic of China
| | - Yingzhu Chen
- Clinical Medical College, Yangzhou University, Yangzhou City, Jiangsu Province, People's Republic of China.,Department of Neurology, Northern Jiangsu Province Hospital, Yangzhou City, Jiangsu Province, People's Republic of China
| |
Collapse
|
57
|
Systemic High-Mobility Group Box-1: A Novel Predictive Biomarker for Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Crit Care Med 2019; 46:e1023-e1028. [PMID: 30028365 DOI: 10.1097/ccm.0000000000003319] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the release of proinflammatory damage-associated molecular pattern molecule "high-mobility group box-1" in the serum of patients after aneurysmal subarachnoid hemorrhage and its association with cerebral vasospasm. DESIGN Retrospective observational study. SETTING University hospital. PATIENTS Aneurysmal subarachnoid hemorrhage patients admitted within 24 hours of ictus. INTERVENTIONS Standard subarachnoid hemorrhage treatment after clipping or coiling of aneurysm. MEASUREMENTS AND MAIN RESULTS We enrolled 53 aneurysmal subarachnoid hemorrhage patients from which peripheral venous blood was withdrawn on days 1, 3, 5, 7, 9, 11, and 13 and once from the controls to obtain the serum. Serum high-mobility group box-1 concentration was quantified by enzyme-linked immunosorbent assay. Serum interleukin-6 and peripheral blood leukocytes were also determined over the first 2 weeks after subarachnoid hemorrhage. Patients' data were recorded prospectively. Serum high-mobility group box-1 was significantly elevated in subarachnoid hemorrhage patients from day 1 to day 13 when compared with nonsubarachnoid hemorrhage patients (p < 0.05). Patients with cerebral vasospasm showed significantly higher high-mobility group box-1 starting from day 1 to day 13 when compared with patients without cerebral vasospasm. Cumulative levels of high-mobility group box-1 showed significant correlation with peripheral blood leukocytes and interleukin-6 levels (p < 0.05). Receiver operating characteristic curve analysis showed that serum high-mobility group box-1 level at admission may be a predictive biomarker for cerebral vasospasm with a sensitivity of 59% and a specificity of 82% at a cutoff value of 5.6 ng/mL. CONCLUSIONS Serum high-mobility group box-1 is differentially elevated after subarachnoid hemorrhage. Serum high-mobility group box-1 levels were elevated early after subarachnoid hemorrhage (day 1) and remained significantly high until day 13 in patients who developed cerebral vasospasm. Our data suggest that serum high-mobility group box-1 may be a predictive biomarker for the detection of CVS.
Collapse
|
58
|
Lucchese G, Flöel A, Stahl B. Cross-Reactivity as a Mechanism Linking Infections to Stroke. Front Neurol 2019; 10:469. [PMID: 31156531 PMCID: PMC6528689 DOI: 10.3389/fneur.2019.00469] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/17/2019] [Indexed: 12/19/2022] Open
Abstract
The relevance of infections as risk factor for cerebrovascular disease is being increasingly recognized. Nonetheless, the pathogenic link between the two entities remains poorly understood. Consistent with recent advances in medicine, the present work addresses the hypothesis that infection-induced immune responses may affect human proteins associated with stroke. Applying established procedures in bioinformatics, the pathogen antigens and the human proteins were searched for common sequences using pentapeptides as probes. The resulting data demonstrate massive peptide sharing between infectious pathogens-such as Chlamydia pneumoniae, Streptococcus pneumoniae, Tannerella forsythia, Haemophilus influenzae, Influenza A virus, and Cytomegalovirus-and human proteins related to risk of ischemic and hemorrhagic stroke. Moreover, the shared peptides are also evident in a number of epitopes experimentally proven immunopositive in the human host. The present findings suggest cross-reactivity as a potential mechanistic link between infections and stroke.
Collapse
Affiliation(s)
- Guglielmo Lucchese
- Department of Neurology, University of Greifswald, Greifswald, Germany.,Department of Computing, Goldsmiths, University of London, London, United Kingdom
| | - Agnes Flöel
- Department of Neurology, University of Greifswald, Greifswald, Germany
| | - Benjamin Stahl
- Department of Neurology, University of Greifswald, Greifswald, Germany.,Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Psychologische Hochschule Berlin, Berlin, Germany
| |
Collapse
|
59
|
Fountoulaki K, Tsiodras S, Polyzogopoulou E, Olympios C, Parissis J. Beneficial Effects of Vaccination on Cardiovascular Events: Myocardial Infarction, Stroke, Heart Failure. Cardiology 2018; 141:98-106. [DOI: 10.1159/000493572] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 09/07/2018] [Indexed: 12/28/2022]
Abstract
Influenza and pneumococcal infections have been suggested to be potential risk factors for causing adverse cardiovascular events, especially in high-risk patients. Vaccination against respiratory infections in patients with established cardiovascular disease (CVD) could serve as a potential cost-effective intervention to improve their clinical outcomes and cardiac societies have encouraged it. Previous studies have shown that influenza vaccination reduce mortality, acute coronary syndromes and hospitalization in patients with coronary heart disease (CHD) and/or heart failure (HF). However, there is a paucity of randomized prospective clinical trials in the field of the pneumococcal vaccination, and additional higher-quality evidence is needed. Furthermore, questions around the role of vaccination in the primary prevention of CVD, the optimal dose and timing are largely unanswered. The pathophysiologic mechanism in which vaccination provides cardiovascular protection may be related to the modification of the immune-inflammatory model of atherogenesis. The present review summarizes the current evidence and understanding for vaccination against influenza and streptococcus pneumoniae in CHD, HF and stroke and highlights its beneficial effect in the reduction of adverse cardiovascular events.
Collapse
|
60
|
Yandrapalli S, Aronow WS, Frishman WH. Readmissions in adult patients following hospitalization for influenza: a nationwide cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:318. [PMID: 30363955 DOI: 10.21037/atm.2018.07.18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Influenza epidemics are a major health care concern in the US. Influenza related complications can increase in-hospital complications, and readmissions following a hospitalization for influenza. We sought to determine the 30-day readmission rate, etiologies, outcomes, and healthcare burden of 30-day readmissions in adults hospitalized for influenza. Methods The 2014 US National Readmissions Database (NRD) was retrospectively analyzed to identify patients ≥18 years of age hospitalized for influenza and discharged between January and November 2014. We used this time frame as this was the most recent data available for analysis and included patients who had 30-day follow-up. Survey design based multivariable logistic regression models were used to identify factors associated with a 30-day readmission. Results Of the 46,117 patients who were hospitalized for influenza and survived to discharge, 4,721 (10.2%) patients had 5,275 30-day readmissions, estimated to 11.4 readmissions per 100 patients. Non-influenza pneumonia was the most common etiology of 30-day readmissions (10.4%) followed by sepsis (9.8%). The median costs of readmissions were $8,538 (IQR, $5,053-15,262), which were significantly higher than the median costs of their index hospitalizations [$7,863 (IQR, $4,875-13,212); P<0.001]. Around 6.5% of the patients died during a readmission. Conclusions Adult patients hospitalized for influenza had 11.4 30-day readmissions per 100 patients, most commonly for non-influenza pneumonia. Thirty-day readmissions were associated with higher costs of care and considerable mortality.
Collapse
Affiliation(s)
- Srikanth Yandrapalli
- Department of Medicine, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Wilbert S Aronow
- Department of Medicine, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - William H Frishman
- Department of Medicine, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| |
Collapse
|
61
|
Liu Y, Gong P, Wang M, Zhou J. Seasonal variation of admission severity and outcomes in ischemic stroke - a consecutive hospital-based stroke registry. Chronobiol Int 2018; 35:295-302. [PMID: 29372813 DOI: 10.1080/07420528.2017.1369430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Different morbidities and mortalities of ischemic stroke may occur among seasons. For detecting the seasonal variations of severity after stroke onset and prognosis, we employed a retrospective analysis on a prospective regional hospital-based stroke registry and included a total of 1039 consecutive patients with onset date from January 2014 to December 2015. Patients were divided into four groups according to the onset seasons. Baseline characteristics, stroke subtypes, admission National Institute of Health Stroke Scale (NIHSS) score and modified Rankin Scale (mRS) score in 90 d were recorded and compared. Ordinal logistic regression was used to evaluate the association of seasons and severity or outcomes. Higher proportion of cardiac embolisms appeared in spring and winter (p < 0.001). The median admission NIHSS score was 5 in spring, 3 in summer, 4 in fall and 4 in winter (p = 0.036). After 90 d from onset, 40.5% of patients in spring suffered poor outcome (mRS 3-6), while 24.6% in summer, 33.9% in fall and 40.1% in winter (p < 0.001). After adjusted for age, sex, stroke subtypes and other covariates, patients in spring and winter had 1.76 times (95%CI 1.14-2.70, p = 0.010) and 1.53 times (95%CI 1.08-2.18, p = 0.017) the risk of suffering higher severity category than patients in summer, respectively. Compared with summer group, risk of worse outcomes at 90 d increased to 2.30 times in spring (95%CI 1.53-3.45, p < 0.001), 1.57 times in fall (95%CI 1.14-2.16, p = 0.006) and 2.09 times in winter (95%CI 1.50-2.91, p < 0.001), respectively. In conclusion, onset seasons were associated with severity and outcomes in ischemic stroke, and patients admitted in spring and winter had more severity and worse outcomes than patients in summer.
Collapse
Affiliation(s)
- Yukai Liu
- a Department of Neurology , Nanjing First Hospital, Nanjing Medical University , Nanjing , P.R. China
| | - Pengyu Gong
- a Department of Neurology , Nanjing First Hospital, Nanjing Medical University , Nanjing , P.R. China
| | - Meng Wang
- a Department of Neurology , Nanjing First Hospital, Nanjing Medical University , Nanjing , P.R. China
| | - Junshan Zhou
- a Department of Neurology , Nanjing First Hospital, Nanjing Medical University , Nanjing , P.R. China
| |
Collapse
|
62
|
Tsivgoulis G, Katsanos AH, Zand R, Ishfaq MF, Malik MT, Karapanayiotides T, Voumvourakis K, Tsiodras S, Parissis J. The association of adult vaccination with the risk of cerebrovascular ischemia: A systematic review and meta-analysis. J Neurol Sci 2018; 386:12-18. [PMID: 29406959 DOI: 10.1016/j.jns.2018.01.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 12/19/2017] [Accepted: 01/06/2018] [Indexed: 01/13/2023]
Abstract
There is mounting evidence supporting infection as an independent risk factor for ischemic stroke (IS), while preliminary data indicate that vaccination may prevent IS. We performed a systematic review and meta-analysis of available randomized clinical trials (RCTs) or prospective observational cohorts reporting associations of influenza vaccination (IV) and/or pneumococcal vaccination (PV) with IS. We identified a total of 12 studies (543,311 patients; 47.4% vaccinated). Vaccination was not related to the risk of IS (RR=1.06, 95%CI: 0.74-1.51, p=0.77), with no significant differences (p=0.26) among RCTs (RR=0.66, 95%CI: 0.30-1.47) and observational studies (RR=1.11, 95%CI: 0.76-1.61). Evidence of considerable heterogeneity was identified within observational studies (I2=98%), but not within RCTs (I2=0%). In subgroup analyses according to vaccination type, IV was associated with a significantly lower risk of IS (RR=0.87, 95%CI: 0.79-0.96, p=0.004) with moderate evidence of heterogeneity (I2=53%). No association was seen for PV (RR=1.38, 95%CI: 0.60-3.16, p=0.45), where considerable heterogeneity was identified (I2=97%). In the additional adjusted analyses of observational studies, vaccination tended to be associated with lower risk of IS (HRadjusted=0.87; 95%CI: 0.75-1.01; p=0.07). The findings of this meta-analysis indicate that IV may be associated with a lower risk of IS. This association was not reproduced for PV or the combination of two vaccines. Substantial heterogeneity was detected across observational studies for all outcome events, while moderate to low heterogeneity was identified across included RCTs. These preliminary findings require independent validation in large RCTs.
Collapse
Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens School of Medicine, Athens, Greece; Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Aristeidis H Katsanos
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens School of Medicine, Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Ramin Zand
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurology, Geisinger Health System, Danville, PA, USA
| | - Muhammad Fawad Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Theodore Karapanayiotides
- Second Department of Neurology, "AHEPA" University Hospital, School of Medicine, Aristoteleion University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - John Parissis
- Second Department of Cardiology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
63
|
Marcet P, Santos N, Borlongan CV. When friend turns foe: central and peripheral neuroinflammation in central nervous system injury. ACTA ACUST UNITED AC 2017; 4:82-92. [PMID: 29670933 PMCID: PMC5901724 DOI: 10.20517/2347-8659.2017.07] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Injury to the central nervous system (CNS) is common, and though it has been well studied, many aspects of traumatic brain injury (TBI) and stroke are poorly understood. TBI and stroke are two pathologic events that can cause severe, immediate impact to the neurostructure and function of the CNS, which has been recognized recently to be exacerbated by the body’s own immune response. Although the brain damage induced by the initial trauma is most likely unsalvageable, the secondary immunologic deterioration of neural tissue gives ample opportunity for therapeutic strategists seeking to mitigate TBI’s secondary detrimental effects. The purpose of this paper is to highlight the cell death mechanisms associated with CNS injury with special emphasis on inflammation. The authors discuss sources of inflammation, and introduce the role of the spleen in the systemic response to inflammation after CNS injury.
Collapse
Affiliation(s)
- Paul Marcet
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA
| | - Nicole Santos
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA
| | - Cesar V Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA
| |
Collapse
|
64
|
LeBras MH, Barry AR. Influenza Vaccination for Secondary Prevention of Cardiovascular Events: A Systematic Review. Can J Hosp Pharm 2017; 70:27-34. [PMID: 28348430 DOI: 10.4212/cjhp.v70i1.1626] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Influenza is a common respiratory infection that may cause complications, including cardiovascular events. Influenza illness has been shown to double the risk of myocardial infarction, with the highest risk among patients with established cardiovascular disease. Vaccination against influenza has been associated with reductions in myocardial infarction, cerebrovascular disease, and death. OBJECTIVE To evaluate the evidence for influenza vaccination as a strategy to reduce cardiovascular events specifically in patients with established cardiovascular disease. DATA SOURCES AND STUDY SELECTION MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched with the terms "influenza vaccine" and "cardiovascular disease". Included in this review were randomized controlled trials (RCTs), nonrandomized studies, and meta-analyses that compared influenza vaccination against control in patients with established cardiovascular disease and that reported clinically meaningful cardiovascular outcomes (defined as cardiovascular death, myocardial infarction, and stroke). DATA EXTRACTION AND SYNTHESIS The search yielded 10 studies (3 nonrandomized studies, 5 RCTs, and 2 meta-analyses). The nonrandomized studies and the RCTs had inconsistent results with respect to cardiovascular death and adverse cardiovascular events. The 2 meta-analyses, which included the same 4 RCTs involving patients with established cardiovascular disease, showed that the influenza vaccine reduced cardiovascular death by about 50% relative to control. Vaccination also reduced major cardiovascular events by about 43%; the reduction was greater (54%) in the subgroup of patients with recent (≤ 1 year) acute coronary syndrome. However, these data are potentially confounded by small sample sizes, low event rates, and variable outcome reporting. There was also high clinical heterogeneity among the studies, which may not reflect contemporary practice. CONCLUSIONS Given the limitations of these data, it is unclear whether the cardiovascular benefit with influenza vaccination in patients with cardiovascular disease is a true effect. Nevertheless, because of the potential benefit and the low risk of adverse events, the annual influenza vaccine should be recommended for all patients with established cardiovascular disease.
Collapse
Affiliation(s)
- Marlys H LeBras
- , BSP, PharmD, ACPR, was, at the time of writing, with the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia. She is now with the RxFiles Academic Detailing Program, Saskatoon Health Region, Saskatoon, Saskatchewan
| | - Arden R Barry
- , BSc, BSc(Pharm), PharmD, ACPR, is with the Chilliwack General Hospital, Lower Mainland Pharmacy Services, Chilliwack, British Columbia, and the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| |
Collapse
|
65
|
Muhammad S, Planz O, Schwaninger M. Increased Plasma Matrix Metalloproteinase-9 Levels Contribute to Intracerebral Hemorrhage during Thrombolysis after Concomitant Stroke and Influenza Infection. Cerebrovasc Dis Extra 2016; 6:50-9. [PMID: 27560521 PMCID: PMC5040893 DOI: 10.1159/000447750] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 06/16/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thrombolysis is the only approved therapy for acute stroke. However, life-threatening complications such as intracerebral hemorrhage (ICH) can develop after intravenous administration of tissue plasminogen activator (tPA). Both infection and thrombolysis during cerebral ischemia disrupt the blood-brain barrier (BBB). tPA can induce matrix metalloproteinase-9 (MMP-9), which is known to be involved in BBB disruption. However, it has still not been investigated whether preexisting influenza virus infection during thrombolysis after acute stroke affects systemic levels of MMP-9 and its inhibitor TIMP-1 and whether increased systemic MMP-9 levels affect ICH. This study aimed to investigate the influence of influenza virus infection on plasma levels of MMP-9 and TIMP-1 after thrombolysis in acute stroke, and to determine whether the infection correlates with intracerebral bleeding. METHODS C57BL/6 mice were infected by administering 1 × 105 plaque-forming units of human influenza (H1N1) virus intranasally. After 3 days of infection the middle cerebral artery was occluded for 45 min and then reperfused. Intravenous tPA (10 mg/kg) treatment was started 10 min after stroke onset. Twenty-four hours after stroke onset, mice were deeply anesthetized with ketamine, venous blood was drawn from the caval vein and centrifuged at 2,000 rpm, and the supernatant was collected and frozen at -80°C. Plasma levels of MMP-9 and TIMP-1 were quantified by using ELISA. RESULTS After stroke, plasma MMP-9 was significantly increased in mice with a concomitant influenza infection that were treated with tPA (9.99 ± 0.62 ng/ml, n = 7) as compared to noninfected control mice that were treated with tPA (4.74 ± 0.48 ng/ml, n = 8). Moreover, plasma levels of TIMP-1, an inhibitor of MMP-9, were also significantly increased in mice treated with tPA after concomitant infection and stroke (42.17 ± 7.02 ng/ml, n = 7) as compared to noninfected control mice that were treated with tPA after stroke (20.22 ± 2.12 ng/ml, n = 8). MMP-9 values significantly correlated with intracerebral hemoglobin levels in animals treated with tPA after stroke (p = 0.028, r = 0.76, n = 8) and after concomitant stroke and infection (p = 0.039, r = 0.78, n = 7). CONCLUSION Preexisting influenza A virus infection led to increased plasma MMP-9 and TIMP-1 levels in mice undergoing thrombolysis after induced stroke. MMP-9 levels closely correlated with intracerebral bleeding after thrombolysis during concomitant infection and stroke. Thus, our data indicate that thrombolysis may be dangerous during influenza infection. MMP-9 inhibitors might be considered to reduce the side effects of thrombolysis during concomitant infection and stroke.
Collapse
Affiliation(s)
- Sajjad Muhammad
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Pharmacology, University of Heidelberg, Heidelberg, Germany
- *Dr. med. Sajjad Muhammad, Department of Neurosurgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, DE-53127 Bonn (Germany), E-Mail
| | - Oliver Planz
- Department of Immunology, University of Tübingen, Tübingen, Germany
| | - Markus Schwaninger
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany
- Department of Pharmacology, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
66
|
Rasouli J, Lekhraj R, Ozbalik M, Lalezari P, Casper D. Brain-Spleen Inflammatory Coupling: A Literature Review. ACTA ACUST UNITED AC 2016; 27:74-77. [PMID: 22611344 DOI: 10.23861/ejbm20112768] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent evidence suggests a link between brain injury and the autonomic release of pro-inflammatory cytokines by resident macrophages in the spleen. This phenomenon, termed "brain-spleen inflammatory coupling," has garnered attention from scientific and medical communities interested in developing novel treatments for traumatic brain injury (TBI). Cholinergic stimulation of the α7-subunit nicotinic acetylcholine receptor (α7NAchR) on splenic macrophages has been shown to inhibit their release of pro-inflammatory cytokines. This inhibition, mediated by the parasympathetic nervous system, has been shown to improve outcomes in animal models of sepsis, stroke, and TBI. As evidence of a beneficial role of splenic inhibition grows, new treatment strategies might be applied to many medical conditions involving neuroinflammation, a process that contributes to further neurological deterioration.
Collapse
Affiliation(s)
- J Rasouli
- Albert Einstein College of Medicine, Bronx NY 10461
| | | | | | | | | |
Collapse
|
67
|
Brough D, Denes A. Interleukin-1α and brain inflammation. IUBMB Life 2015; 67:323-30. [PMID: 25906979 DOI: 10.1002/iub.1377] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 03/16/2015] [Indexed: 12/12/2022]
Abstract
Acute brain injuries such as caused by stroke are amongst the leading causes of death and are the leading cause of disability. Despite this there are very limited therapeutic options, and new therapeutic strategies and targets are required. Inflammation is known to exacerbate brain injury and is now considered as a potential therapeutic target. The damaging inflammation that occurs after acute brain injury is driven by pro-inflammatory members of the interleukin (IL)-1 cytokine family, namely, IL-1α and IL-1β. Previous research efforts have focussed on the biology and contribution of IL-1β. However, we now recognise that IL-1α is an early and important mediator of inflammation after injury. This review focuses on what is known about IL-1α, its regulation and its contribution to brain injury. Inhibiting mechanisms regulating the processing and release of IL-1α may offer new therapeutic targets for the treatment of devastating acute brain injuries.
Collapse
Affiliation(s)
- David Brough
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Adam Denes
- Faculty of Life Sciences, University of Manchester, Manchester, UK.,Laboratory of Molecular Neuroendocrinology, Institute of Experimental Medicine, Budapest, Hungary
| |
Collapse
|
68
|
Abstract
Acute systemic inflammatory reaction superimposed on chronic low-grade inflammation accompanies acute ischemic stroke. Elevated blood levels of systemic inflammatory markers such as IL-6 or C-reactive protein are associated with an unfavorable functional outcome and increased mortality after stroke. Animal studies have demonstrated a causal relationship between systemic inflammation and ischemic brain damage. The mechanisms linking systemic inflammation with poor outcome include increased neutrophil infiltration of cerebral cortex, disruption of the blood-brain barrier, impaired tissue reperfusion, increased platelet activation and microvascular coagulation and complement-dependent brain injury. Non-selective (e.g., by statins) or selective (e.g., by inhibition of IL-6) attenuation of systemic inflammation, enhancement of systemic anti-inflammatory response (e.g., by infusion of IL-1 receptor antagonist), prevention of infections that exacerbate systemic inflammation or inhibition of neuronal pathways triggering inflammatory reaction are potential therapeutic targets in stroke patients. This review discusses the relationship between systemic inflammation, cerebral ischemia and prognosis in the context of therapeutic strategies.
Collapse
Affiliation(s)
- Tomasz Dziedzic
- Department of Neurology, Jagiellonian University Medical Collage, ul. Botaniczna 3, 31-503 Kraków, Poland
| |
Collapse
|
69
|
Murray KN, Parry-Jones AR, Allan SM. Interleukin-1 and acute brain injury. Front Cell Neurosci 2015; 9:18. [PMID: 25705177 PMCID: PMC4319479 DOI: 10.3389/fncel.2015.00018] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/12/2015] [Indexed: 01/05/2023] Open
Abstract
Inflammation is the key host-defense response to infection and injury, yet also a major contributor to a diverse range of diseases, both peripheral and central in origin. Brain injury as a result of stroke or trauma is a leading cause of death and disability worldwide, yet there are no effective treatments, resulting in enormous social and economic costs. Increasing evidence, both preclinical and clinical, highlights inflammation as an important factor in stroke, both in determining outcome and as a contributor to risk. A number of inflammatory mediators have been proposed as key targets for intervention to reduce the burden of stroke, several reaching clinical trial, but as yet yielding no success. Many factors could explain these failures, including the lack of robust preclinical evidence and poorly designed clinical trials, in addition to the complex nature of the clinical condition. Lack of consideration in preclinical studies of associated co-morbidities prevalent in the clinical stroke population is now seen as an important omission in previous work. These co-morbidities (atherosclerosis, hypertension, diabetes, infection) have a strong inflammatory component, supporting the need for greater understanding of how inflammation contributes to acute brain injury. Interleukin (IL)-1 is the prototypical pro-inflammatory cytokine, first identified many years ago as the endogenous pyrogen. Research over the last 20 years or so reveals that IL-1 is an important mediator of neuronal injury and blocking the actions of IL-1 is beneficial in a number of experimental models of brain damage. Mechanisms underlying the actions of IL-1 in brain injury remain unclear, though increasing evidence indicates the cerebrovasculature as a key target. Recent literature supporting this and other aspects of how IL-1 and systemic inflammation in general contribute to acute brain injury are discussed in this review.
Collapse
Affiliation(s)
- Katie N Murray
- Faculty of Life Sciences, University of Manchester Manchester, UK
| | | | - Stuart M Allan
- Faculty of Life Sciences, University of Manchester Manchester, UK
| |
Collapse
|
70
|
Urra X, Miró F, Chamorro A, Planas AM. Antigen-specific immune reactions to ischemic stroke. Front Cell Neurosci 2014; 8:278. [PMID: 25309322 PMCID: PMC4162361 DOI: 10.3389/fncel.2014.00278] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/22/2014] [Indexed: 12/24/2022] Open
Abstract
Brain proteins are detected in the cerebrospinal fluid (CSF) and blood of stroke patients and their concentration is related to the extent of brain damage. Antibodies against brain antigens develop after stroke, suggesting a humoral immune response to the brain injury. Furthermore, induced immune tolerance is beneficial in animal models of cerebral ischemia. The presence of circulating T cells sensitized against brain antigens, and antigen presenting cells (APCs) carrying brain antigens in draining lymphoid tissue of stroke patients support the notion that stroke might induce antigen-specific immune responses. After stroke, brain proteins that are normally hidden from the periphery, inflammatory mediators, and danger signals can exit the brain through several efflux routes. They can reach the blood after leaking out of the damaged blood-brain barrier (BBB) or following the drainage of interstitial fluid to the dural venous sinus, or reach the cervical lymph nodes through the nasal lymphatics following CSF drainage along the arachnoid sheaths of nerves across the nasal submucosa. The route and mode of access of brain antigens to lymphoid tissue could influence the type of response. Central and peripheral tolerance prevents autoimmunity, but the actual mechanisms of tolerance to brain antigens released into the periphery in the presence of inflammation, danger signals, and APCs, are not fully characterized. Stroke does not systematically trigger autoimmunity, but under certain circumstances, such as pronounced systemic inflammation or infection, autoreactive T cells could escape the tolerance controls. Further investigation is needed to elucidate whether antigen-specific immune events could underlie neurological complications impairing recovery from stroke.
Collapse
Affiliation(s)
- Xabier Urra
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic Barcelona, Spain ; August Pi i Sunyer Biomedical Research Institute (IDIBAPS) Barcelona, Spain
| | - Francesc Miró
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS) Barcelona, Spain
| | - Angel Chamorro
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic Barcelona, Spain ; August Pi i Sunyer Biomedical Research Institute (IDIBAPS) Barcelona, Spain
| | - Anna M Planas
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS) Barcelona, Spain ; Department of Brain Ischemia and Neurodegeneration, Instituto de Investigaciones Biomédicas de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC) Barcelona, Spain
| |
Collapse
|
71
|
Dénes Á, Pradillo JM, Drake C, Sharp A, Warn P, Murray KN, Rohit B, Dockrell DH, Chamberlain J, Casbolt H, Francis S, Martinecz B, Nieswandt B, Rothwell NJ, Allan SM. Streptococcus pneumoniae worsens cerebral ischemia via interleukin 1 and platelet glycoprotein Ibα. Ann Neurol 2014; 75:670-83. [PMID: 24644058 DOI: 10.1002/ana.24146] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 03/17/2014] [Accepted: 03/17/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Bacterial infection contributes to diverse noninfectious diseases and worsens outcome after stroke. Streptococcus pneumoniae, the most common infection in patients at risk of stroke, is a major cause of prolonged hospitalization and death of stroke patients, but how infection impacts clinical outcome is not known. METHODS We induced sustained pulmonary infection by a human S. pneumoniae isolate in naive and comorbid rodents to investigate the effect of infection on vascular and inflammatory responses prior to and after cerebral ischemia. RESULTS S. pneumoniae infection triggered atherogenesis, led to systemic induction of interleukin (IL) 1, and profoundly exacerbated (50-90%) ischemic brain injury in rats and mice, a response that was more severe in combination with old age and atherosclerosis. Systemic blockade of IL-1 with IL-1 receptor antagonist (IL-1Ra) fully reversed infection-induced exacerbation of brain injury and functional impairment caused by cerebral ischemia. We show that infection-induced systemic inflammation mediates its effects via increasing platelet activation and microvascular coagulation in the brain after cerebral ischemia, as confirmed by reduced brain injury in response to blockade of platelet glycoprotein (GP) Ibα. IL-1 and platelet-mediated signals converge on microglia, as both IL-1Ra and GPIbα blockade reversed the production of IL-1α by microglia in response to cerebral ischemia in infected animals. INTERPRETATION S. pneumoniae infection augments atherosclerosis and exacerbates ischemic brain injury via IL-1 and platelet-mediated systemic inflammation. These mechanisms may contribute to diverse cardio- and cerebrovascular pathologies in humans.
Collapse
Affiliation(s)
- Ádám Dénes
- Faculty of Life Sciences, University of Manchester, Manchester, United Kingdom; Laboratory of Molecular Neuroendocrinology, Institute of Experimental Medicine, Budapest, Hungary
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
72
|
Lin HC, Chiu HF, Ho SC, Yang CY. Association of influenza vaccination and reduced risk of stroke hospitalization among the elderly: a population-based case-control study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2014; 11:3639-49. [PMID: 24699027 PMCID: PMC4025018 DOI: 10.3390/ijerph110403639] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/13/2014] [Accepted: 03/19/2014] [Indexed: 11/16/2022]
Abstract
The aim of this study was to investigate the effect of influenza vaccination (and annual revaccination) on the risk of stroke admissions. We conducted a population-based case-control study in Taiwan. Cases consisted of patients >65 years of age who had a first-time diagnosis of stroke during the influenza seasons from 2006 to 2009. Controls were selected by matching age, sex, and index date to cases. Multiple logistic regression analysis was used to calculate the adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Ever vaccinated individuals in the current vaccination season were associated with a reduced risk of ischemic stroke admissions (OR = 0.76, 95% CI = 0.60-0.97). Compared with individuals never vaccinated against influenza during the past 5 years, the adjusted ORs were 0.92 (95% CI = 0.68-1.23) for the group with 1 or 2 vaccinations, 0.73 (95% CI = 0.54-1.00) for the group with 3 or 4 vaccinations, and 0.56 (95% CI = 0.38-0.83) for the group with 5 vaccinations. There was a significant trend of decreasing risk of ischemic stroke admissions with an increasing number of vaccinations. This study provides evidence that vaccination against influenza may reduce the risk of hospitalization for ischemic stroke and that annual revaccination provides greater protection.
Collapse
Affiliation(s)
- Hui-Chen Lin
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
| | - Hui-Fen Chiu
- Institute of Pharmacology, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
| | - Shu-Chen Ho
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
| | - Chun-Yuh Yang
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung 807, Taiwan.
| |
Collapse
|
73
|
Dhungana H, Malm T, Denes A, Valonen P, Wojciechowski S, Magga J, Savchenko E, Humphreys N, Grencis R, Rothwell N, Koistinaho J. Aging aggravates ischemic stroke-induced brain damage in mice with chronic peripheral infection. Aging Cell 2013; 12:842-50. [PMID: 23725345 DOI: 10.1111/acel.12106] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2013] [Indexed: 01/13/2023] Open
Abstract
Ischemic stroke is confounded by conditions such as atherosclerosis, diabetes, and infection, all of which alter peripheral inflammatory processes with concomitant impact on stroke outcome. The majority of the stroke patients are elderly, but the impact of interactions between aging and inflammation on stroke remains unknown. We thus investigated the influence of age on the outcome of stroke in animals predisposed to systemic chronic infection. Th1-polarized chronic systemic infection was induced in 18-22 month and 4-month-old C57BL/6j mice by administration of Trichuris muris (gut parasite). One month after infection, mice underwent permanent middle cerebral artery occlusion and infarct size, brain gliosis, and brain and plasma cytokine profiles were analyzed. Chronic infection increased the infarct size in aged but not in young mice at 24 h. Aged, ischemic mice showed altered plasma and brain cytokine responses, while the lesion size correlated with plasma prestroke levels of RANTES. Moreover, the old, infected mice exhibited significantly increased neutrophil recruitment and upregulation of both plasma interleukin-17α and tumor necrosis factor-α levels. Neither age nor infection status alone or in combination altered the ischemia-induced brain microgliosis. Our results show that chronic peripheral infection in aged animals renders the brain more vulnerable to ischemic insults, possibly by increasing the invasion of neutrophils and altering the inflammation status in the blood and brain. Understanding the interactions between age and infections is crucial for developing a better therapeutic regimen for ischemic stroke and when modeling it as a disease of the elderly.
Collapse
Affiliation(s)
- Hiramani Dhungana
- Department of Neurobiology; A. I. Virtanen Institute for Molecular Sciences; Biocenter Kuopio; University of Eastern Finland; PO Box 1627; FI-70211; Kuopio; Finland
| | - Tarja Malm
- Department of Neurobiology; A. I. Virtanen Institute for Molecular Sciences; Biocenter Kuopio; University of Eastern Finland; PO Box 1627; FI-70211; Kuopio; Finland
| | | | - Piia Valonen
- Department of Neurobiology; A. I. Virtanen Institute for Molecular Sciences; Biocenter Kuopio; University of Eastern Finland; PO Box 1627; FI-70211; Kuopio; Finland
| | - Sara Wojciechowski
- Department of Neurobiology; A. I. Virtanen Institute for Molecular Sciences; Biocenter Kuopio; University of Eastern Finland; PO Box 1627; FI-70211; Kuopio; Finland
| | - Johanna Magga
- Department of Neurobiology; A. I. Virtanen Institute for Molecular Sciences; Biocenter Kuopio; University of Eastern Finland; PO Box 1627; FI-70211; Kuopio; Finland
| | - Ekaterina Savchenko
- Department of Neurobiology; A. I. Virtanen Institute for Molecular Sciences; Biocenter Kuopio; University of Eastern Finland; PO Box 1627; FI-70211; Kuopio; Finland
| | - Neil Humphreys
- Faculty of Life Sciences; University of Manchester; Oxford Road; Manchester; M13 9PT; UK
| | - Richard Grencis
- Faculty of Life Sciences; University of Manchester; Oxford Road; Manchester; M13 9PT; UK
| | - Nancy Rothwell
- Faculty of Life Sciences; University of Manchester; Oxford Road; Manchester; M13 9PT; UK
| | | |
Collapse
|
74
|
Smith CJ, Lawrence CB, Rodriguez-Grande B, Kovacs KJ, Pradillo JM, Denes A. The immune system in stroke: clinical challenges and their translation to experimental research. J Neuroimmune Pharmacol 2013; 8:867-87. [PMID: 23673977 DOI: 10.1007/s11481-013-9469-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 04/28/2013] [Indexed: 12/27/2022]
Abstract
Stroke represents an unresolved challenge for both developed and developing countries and has a huge socio-economic impact. Although considerable effort has been made to limit stroke incidence and improve outcome, strategies aimed at protecting injured neurons in the brain have all failed. This failure is likely to be due to both the incompleteness of modelling the disease and its causes in experimental research, and also the lack of understanding of how systemic mechanisms lead to an acute cerebrovascular event or contribute to outcome. Inflammation has been implicated in all forms of brain injury and it is now clear that immune mechanisms profoundly influence (and are responsible for the development of) risk and causation of stroke, and the outcome following the onset of cerebral ischemia. Until very recently, systemic inflammatory mechanisms, with respect to common comorbidities in stroke, have largely been ignored in experimental studies. The main aim is therefore to understand interactions between the immune system and brain injury in order to develop novel therapeutic approaches. Recent data from clinical and experimental research clearly show that systemic inflammatory diseases -such as atherosclerosis, obesity, diabetes or infection - similar to stress and advanced age, are associated with dysregulated immune responses which can profoundly contribute to cerebrovascular inflammation and injury in the central nervous system. In this review, we summarize recent advances in the field of inflammation and stroke, focusing on the challenges of translation between pre-clinical and clinical studies, and potential anti-inflammatory/immunomodulatory therapeutic approaches.
Collapse
Affiliation(s)
- Craig J Smith
- Stroke and Vascular Research Centre, Institute of Cardiovascular Sciences, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford M6 8HD, UK.
| | | | | | | | | | | |
Collapse
|
75
|
Acute myocardial infarctions, strokes and influenza: seasonal and pandemic effects. Epidemiol Infect 2013; 141:735-44. [PMID: 23286343 DOI: 10.1017/s0950268812002890] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The incidence of myocardial infarctions and influenza follow similar seasonal patterns. To determine if acute myocardial infarctions (AMIs) and ischaemic strokes are associated with influenza activity, we built time-series models using data from the Nationwide Inpatient Sample. In these models, we used influenza activity to predict the incidence of AMI and ischaemic stroke. We fitted national models as well as models based on four geographical regions and five age groups. Across all models, we found consistent significant associations between AMIs and influenza activity, but not between ischaemic strokes and influenza. Associations between influenza and AMI increased with age, were greatest in those aged >80 years, and were present in all geographical regions. In addition, the natural experiment provided by the second wave of the influenza pandemic in 2009 provided further evidence of the relationship between influenza and AMI, because both series peaked in the same non-winter month.
Collapse
|
76
|
|
77
|
Murray KN, Buggey HF, Denes A, Allan SM. Systemic immune activation shapes stroke outcome. Mol Cell Neurosci 2012; 53:14-25. [PMID: 23026562 DOI: 10.1016/j.mcn.2012.09.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 09/11/2012] [Accepted: 09/21/2012] [Indexed: 02/07/2023] Open
Abstract
Stroke is a major cause of morbidity and mortality, and activation of the immune system can impact on stroke outcome. Although the majority of research has focused on the role of the immune system after stroke there is increasing evidence to suggest that inflammation and immune activation prior to brain injury can influence stroke risk and outcome. With the high prevalence of co-morbidities in the Western world such as obesity, hypertension and diabetes, pre-existing chronic 'low-grade' systemic inflammation has become a customary characteristic of stroke pathophysiology that needs to be considered in the search for new therapies. The importance of the immune system in stroke has been demonstrated in a number of ways, both experimentally and in the clinical setting. This review will focus on the effect of immune activation arising from systemic inflammatory conditions and infection, how it affects the incidence and outcomes of stroke, and the possible underlying mechanisms involved. This article is part of a Special Issue entitled 'Neuroinflammation in neurodegeneration and neurodysfunction'.
Collapse
Affiliation(s)
- Katie N Murray
- Faculty of Life Sciences, A.V. Hill Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
| | | | | | | |
Collapse
|
78
|
Doyle KP, Buckwalter MS. The double-edged sword of inflammation after stroke: What sharpens each edge? Ann Neurol 2012; 71:729-31. [DOI: 10.1002/ana.23579] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
79
|
Salat D, Campos M, Montaner J. [Advances in the pathophysiology and management of infections in the acute phase of stroke]. Med Clin (Barc) 2012; 139:681-7. [PMID: 22652018 DOI: 10.1016/j.medcli.2012.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 03/14/2012] [Accepted: 03/22/2012] [Indexed: 11/18/2022]
Abstract
Infection in the acute phase of stroke has been identified as an independent predictor of poor outcome, both in the short and intermediate term. Various factors raising the risk of developing an infection (exposure to multiple pathogens, disruption of the protective function of the mucous membranes and a state of relative immunosuppression) coexist during the acute phase of stroke. Several risk factors have been identified for their development (especially increasing age and stroke severity). It has been proposed that infection contributes to a worse prognosis through different mechanisms, notably the development of an inflammatory response to brain tissue (with a potential to add secondary damage to that caused by the ischemic insult). Clinical trials evaluating the prophylactic and early administration of antibiotics to reduce the incidence of infection in the acute phase of stroke have yielded inconsistent results. Immunomodulating strategies, which may provide therapeutic alternatives in the future, are currently being evaluated.
Collapse
Affiliation(s)
- David Salat
- Laboratorio de Investigación Neurovascular, Unidad Neurovascular, Departamento de Neurología, Hospital Vall d'Hebron, Barcelona, España
| | | | | |
Collapse
|
80
|
Denes A, Pinteaux E, Rothwell NJ, Allan SM. Interleukin-1 and stroke: biomarker, harbinger of damage, and therapeutic target. Cerebrovasc Dis 2011; 32:517-27. [PMID: 22104408 DOI: 10.1159/000332205] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 08/26/2011] [Indexed: 12/15/2022] Open
Abstract
Inflammation is established as a contributor to cerebrovascular disease. Risk factors for stroke include many conditions associated with chronic or acute inflammation, and inflammatory changes in the brain after cerebrovascular events contribute to outcome in experimental studies, with growing evidence from clinical research. The brain is extremely susceptible to inflammatory challenge, but resident glia, endothelial cells and neurones can all mount a pronounced inflammatory response to infection or injury. Recent discoveries highlight the importance of peripherally-derived immune cells and inflammatory molecules in various central nervous system disorders, including stroke. The inflammatory cytokine, interleukin-1 (IL-1), plays a pivotal role in both local and systemic inflammation, and is a key driver of peripheral and central immune responses to infection or injury. Inhibition of IL-1 has beneficial effects in a variety of experimental paradigms of acute brain injury and is a promising clinical target in stroke. We propose that blockade of IL-1 could be therapeutically useful in several diseases which are risk factors for stroke, and there is already considerable pre-clinical and clinical evidence that inhibition of IL-1 by IL-1 receptor antagonist may be valuable in the management of acute stroke.
Collapse
Affiliation(s)
- Adam Denes
- Faculty of Life Sciences, University of Manchester, Manchester, UK.
| | | | | | | |
Collapse
|
81
|
Muhammad S, Planz O, Schwaninger M. Response to Letter by McColl et al Regarding Article, “Influenza Virus Infection Aggravates Stroke Outcome”. Stroke 2011. [DOI: 10.1161/strokeaha.111.621441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sajjad Muhammad
- Department of PharmacologyUniversity of HeidelbergHeidelberg, Germany (Muhammad)
| | - Oliver Planz
- Friedrich-Loeffler-InstitutInstitute of ImmunologyTübingen, Germany (Planz)
| | - Markus Schwaninger
- Institute of Experimental and Clinical Pharmacology andToxicologyUniversity of LübeckLübeck, Germany (Schwaninger)
| |
Collapse
|
82
|
Letter by McColl et al Regarding Article, “Influenza Virus Infection Aggravates Stroke Outcome”. Stroke 2011; 42:e416; author reply e417. [DOI: 10.1161/strokeaha.111.621276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
83
|
Grau AJ. Tissue plasminogen activator for stroke and concomitant influenza infection: is this a dangerous combination? Stroke 2011; 42:585-6. [PMID: 21293013 DOI: 10.1161/strokeaha.110.609123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|