D-dimers increase in acute ischemic stroke patients with the large artery occlusion, but do not depend on the time of artery recanalization

National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study

Objectives

To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres.

Design

Outcome-based modelling study.

Setting

107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units).

Participants

242,874 emergency admissions with acute stroke over 3 years (2015–2017).

Intervention

Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO).

Main outcome measures

Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres.

Results

Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres.

Conclusions

Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.

Sex Differences in Hemostatic Factors in Patients With Ischemic Stroke and the Relation With Migraine-A Systematic Review

Background: Women are more affected by stroke than men. This might, in part, be explained by sex differences in stroke pathophysiology. The hemostasis system is influenced by sex hormones and associated with female risk factors for stroke, such as migraine.

Aim: To systematically review possible sex differences in hemostatic related factors in patients with ischemic stroke in general, and the influence of migraine on these factors in women with ischemic stroke.

Results: We included 24 studies with data on sex differences of hemostatic factors in 7247 patients with ischemic stroke (mean age 57–72 years, 27–57% women) and 25 hemostatic related factors. Levels of several factors were higher in women compared with men; FVII:C (116% ± 30% vs. 104% ± 30%), FXI (0.14 UI/mL higher in women), PAI-1 (125.35 ± 49.37 vs. 96.67 ± 38.90 ng/mL), D-dimer (1.25 ± 0.31 vs. 0.95 ± 0.24 μg/mL), and aPS (18.7% vs. 12.0% positive). In contrast, protein-S (86.2% ± 23.0% vs. 104.7% ± 19.8% antigen) and P-selectin (48.9 ± 14.4 vs. 79.1 ± 66.7 pg/mL) were higher in men. Most factors were investigated in single studies, at different time points after stroke, and in different stroke subtypes. Only one small study reported data on migraine and hemostatic factors in women with ischemic stroke. No differences in fibrinogen, D-dimer, t-PA, and PAI-1 levels were found between women with and without migraine.

Conclusion: Our systematic review suggests that sex differences exist in the activation of the hemostatic system in ischemic stroke. Women seem to lean more toward increased levels of procoagulant factors whereas men exhibit increased levels of coagulation inhibitors. To obtain better insight in sex-related differences in hemostatic factors, additional studies are needed to confirm these findings with special attention for different stroke phases, stroke subtypes, and not in the least women specific risk factors, such as migraine.

Cerebral paradoxical embolisation in a patient with cystic fibrosis with patent foramen ovale: a comparative review of literature

A 52-year-old woman with cystic fibrosis presented to the emergency department with expressive aphasia and right-sided hemiparesis. CT scan of the brain revealed a left middle cerebral artery territory infarct. A diagnosis of cerebral paradoxical embolisation associated with patent foramen ovale and a history of deep venous thrombosis was made. The patient underwent endovascular thrombectomy and percutaneous closure of patent foramen ovale. Current literature, including five published case reports, pertaining to the subject is discussed. The unique aspects of the case are highlighted, including the particular risk of cerebral paradoxical embolisation in patients with cystic fibrosis. The result of this case report, in context to previously reported literature, suggests that clinicians should be aware of paradoxical embolisation in patients with cystic fibrosis via an intracardiac shunt, particularly with implanted vascular access devices and a history of deep venous thrombosis.

Plasma D-dimer level is associated with clinical outcomes in patients with atrial fibrillation related acute ischemic stroke after pneumonia

Background

Pneumonia is related to poor prognosis in acute ischemic stroke (AIS), and its risk might be higher in atrial fibrillation (AF) related AIS with elevated plasma D-dimer. The aim of our study was to investigate the prognostic value of D-dimer for predicting clinical outcome of AF-related AIS with pneumonia.

Method

AF-related AIS patients with pneumonia were prospectively enrolled. Receiver operating characteristic (ROC) curve was used to determine the optimal D-dimer point for 3-month mortality and death/severe disability. The associations between the D-dimer and 3-month mortality and death/severe disability were assessed by multivariable logistic regression analysis.

Results

A total of 415 patients were enrolled in this study. ROC curve analysis showed that the optimal cut point of D-dimer for 3-month death/severe disability and mortality were D-dimer≥2.35 mg/l and D-dimer≥3.35 mg/l, respectively. Multivariable logistic regression analysis showed that D-dimer≥2.35 mg/l [adjusted odds ratio (aOR) 5.99, 95% confidence interval (CI): 3.04–11.83, P<0.001], higher NIHISS score (aOR:1.53, 95% CI: 1.38–1.69, P<0.001) and larger infarct volume (aOR 1.01, 95% CI: 1.01–1.02, P<0.001) were associated with increased risk of 3-month death/severe disability), and anticoagulant was associated with decreased risk of death/severe disability (aOR:0.21, 95% CI: 0.09–0.47, P<0.001). Higher NIHISS score (aOR:1.64, 95% CI: 1.38–1.94, P<0.001), older age (aOR 1.08, 95% CI: 1.02–1.14, P = 0.007), D-dimer≥3.35 mg/l (OR 8.49, 95% CI: 4.13–17.84,P<0.001), larger infarct volume (aOR 1.02, 95% CI: 1.00–1.03, P = 0.014), and higher CRUB-65 score (aOR 6.43, 95% CI: 3.10–13.34, P<0.001) were associated with increased risk of 3-month mortality.

Conclusions

AF-related AIS patients with concurrent high D-dimer and pneumonia increased risk of 3-month mortality and death/severe disability, plasma D-dimer may have predictive value in outcome after AF-related AIS with pneumonia.

D-dimer Level is Correlated with Prognosis, Infarct Size, and NIHSS in Acute Ischemic Stroke Patients. Indian J Crit Care Med 2021;25:193-198. [PMID: 33707899 PMCID: PMC7922437 DOI: 10.5005/jp-journals-10071-23744]

Stroke ranks the fourth leading disease causing adult mortality and disability. D-dimer (D-D) is the ultimate product of plasmin-mediated degradation of fibrin-rich thrombi. D-D is a simple readily accessible biomarker employed within the diagnostic algorithms for the exclusion of venous thromboembolism. The correlation between D-D infarct size in MRI brain, APACHE II score, and the National Institute of Health Stroke Scale (NIHSS) score in critically ill acute stroke patients has not been fully investigated before.

Objective

We aimed to investigate the diagnostic and prognostic value of elevated plasma D-D in critically ill patients admitted with acute cerebrovascular accidents. As far as we know, we are the first to investigate the correlation between plasma D-D levels and the ischemic lesion size in MRI brain and also APACHE II score and NIHSS in critically ill acute ischemic cerebrovascular patients.

Setting and participants

A prospective, observational cohort study inside the Critical Care Medicine Department. Thirty patients with AIS were enrolled additionally to 1 healthy age- and sex-matched controls.

Interventions

We employed particle-enhanced, immunoturbidimetric assay to detect plasma D-D concentrations. D-D levels D0 and D1 were measured upon admission and 24 hours later, respectively. We reviewed the patient' s health records; additionally, demographic, clinical, laboratory, and neuroimaging information was abstracted.

Results

D-D concentrations were significantly higher in acute stroke patients compared to healthy controls. ROC curve analysis showed that elevated D-D level more than 310 ng/mL can predict infarct lesion size >1.5 cm in diffusion-weighted MRI brain with sensitivity and specificity (100 and 83%, respectively) and also admission D-D (D0) at cutoff concentration 350 ng/mL and D1 at cutoff value 370 ng/mL are predictors of complicated course with sensitivity and specificity (100 and 84.6%, respectively). There was no significant difference between D0 and D1 D-D levels (p-value >0.05).

Conclusion

The plasma D-D biomarker can be a simple readily available test reliable predictor of infarct lesion size >1.5 cm in DW-MRI and outcome in union with the common practice instrumental tests.

How to cite this article

Abbas NI, Sayed O, Samir S, Abeed N. D-dimer Level is Correlated with Prognosis, Infarct Size, and NIHSS in Acute Ischemic Stroke Patients. Indian J Crit Care Med 2021;25(2):193-198.

S100ß, Matrix Metalloproteinase-9, D-dimer, and Heat Shock Protein 70 Are Serologic Biomarkers of Acute Cerebral Infarction in a Mouse Model of Transient MCA Occlusion

Objective

Diagnosing acute cerebral infarction is crucial in determining prognosis of stroke patients. Although many serologic tests for prompt diagnosis are available, the clinical application of serologic tests is currently limited. We investigated whether S100β, matrix metalloproteinase-9 (MMP-9), D-dimer, and heat shock protein 70 (HSP70) can be used as biomarkers for acute cerebral infarction.

Methods

Focal cerebral ischemia was induced using the modified intraluminal filament technique. Mice were randomly assigned to 30-minute occlusion (n=10), 60-minute occlusion (n=10), or sham (n=5) groups. Four hours later, neurological deficits were evaluated and blood samples were obtained. Infarction volumes were calculated and plasma S100β, MMP-9, D-dimer, and HSP70 levels were measured using enzyme-linked immunosorbent assay.

Results

The average infarction volume was 12.32±2.31 mm³ and 46.9±7.43 mm³ in the 30- and 60-minute groups, respectively. The mean neurological score in the two ischemic groups was 1.6±0.55 and 3.2±0.70, respectively. S100β, MMP-9, and HSP70 expressions significantly increased after 4 hours of ischemia (p=0.001). Furthermore, S100β and MMP-9 expressions correlated with infarction volumes (p<0.001) and neurological deficits (p<0.001). There was no significant difference in D-dimer expression between groups (p=0.843). The area under the receiver operating characteristic curve (AUC) showed high sensitivity and specificity for MMP-9, HSP70 (AUC=1), and S100β (AUC=0.98).

Conclusion

S100β, MMP-9, and HSP70 can complement current diagnostic tools to assess cerebral infarction, suggesting their use as potential biomarkers for acute cerebral infarction.

Plasma D-dimer Level, the Promising Prognostic Biomarker for the Acute Cerebral Infarction Patients

BACKGROUND

Despite being an important cause of death and functional disability, acute cerebral infarction (ACI) lacks accurate and easy tools to predict the outcome of patients beyond clinical variables such as age and stroke severity.

METHODS

To investigate if plasma D-dimer level can be used as such a prognostic biomarker for ACI, so as to better guide patients' management, we studied the association between plasma D-dimer and the functional recovery of 1173 ACI patients. The patients were divided into 2 groups according to modified Rankin Scale (mRS) scores or National Institutes of Health Stroke Scale (NIHSS) scores evaluated on the 30th day after onset.

RESULTS

We observed that plasma D-dimer level correlated significantly with the prognosis of ACI evaluated based on both mRS scores (389.68 ± 32.06 µg/L for poor prognosis versus 377.70 ± 32.68 µg/L for good prognosis, P < .001) and NIHSS scores (387.01 ± 30.60 µg/L for poor prognosis versus 375.23 ± 30.66  µg/L for good prognosis, P < .01). Logistic analysis confirmed that higher D-dimer level was a risk factor for poor prognosis (mRS: odds ratio [OR], 1.604; 95% confidence interval [CI], 1.360-1.892; P < .001; NIHSS: OR, 1.733; 95% CI, 1.461-2.056; P < .01), after adjusted for age, gender, hypertension, diabetes, smoking, and hyperlipidemia.

CONCLUSION

Our results show that plasma D-dimer level is a promising prognosis biomarker for ACI.

Anti-inflammatory and anti-thrombogenic effects of atorvastatin in acute ischemic stroke

Atorvastatin decreases inflammation and thrombogenesis in patients with carotid artery plaque. Atorvastatin is administered to lower lipid levels, but its anti-inflammatory and anti-thrombogenic effects remain unclear. Eighty-nine patients from northeastern China with acute ischemic stroke caused by large-artery atherosclerosis were randomly divided into the study and control groups. All patients received routine treatment, including antiplatelet therapy, circulatory support, and symptomatic treatment. The study group (n = 43) also received daily atorvastatin 20 mg/d, and the control group (n = 46) received daily placebo pills containing glucose. After 4 weeks, the levels of C-reactive protein, fibrinogen, and D-dimer were significantly lower in the study group than in the control group. Decreases in the levels of C-reactive protein, fibrinogen, and D-dimer were not associated with decreases in the levels of triacylglycerol and low-density lipoprotein cholesterol. These results suggest that atorvastatin reduces inflammation and thrombogenesis independent of its lipid-lowering effects in patients with acute ischemic stroke caused by large-artery atherosclerosis.

Cardioembolic stroke diagnosis using blood biomarkers

Stroke is one of the main causes of death and disability in the world. Cardioembolic etiology accounts for approximately one fifth of all ischemic strokes whereas 25-30% remains undetermined even after an advanced diagnostic workup. Despite there is not any biomarker currently approved to distinguish cardioembolic stroke among other etiologies in clinical practice the use of biomarkers represents a promising valuable complement to determine stroke etiology reducing the number of cryptogenic strokes and aiding in the prescription of the most appropriated primary and secondary treatments in order to minimize therapeutic risks and to avoid recurrences. In this review we present an update about specific cardioembolic stroke-related biomarkers at a protein, transcriptomic and genetic level. Finally, we also focused on reported biomarkers associated with atrial fibrillation (a cardiac illness strongly related with cardioembolic stroke subtype) thus with a potential to become biomarkers to detect cardioembolic stroke in the future.

The relationship between plasma D-dimer levels and outcome of Chinese acute ischemic stroke patients in different stroke subtypes

High-level plasma D-dimer suggests hypercoagulable states. There is a lack of correlation study of plasma D-dimer level and prognosis according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. The goal of this study is to explore the relationship between the plasma D-dimer level and the outcome of acute ischemic stroke patients among different stroke subtypes. We conducted a study of acute ischemic stroke patients admitted to the Department of Neurology in Second Hospital of Lanzhou University within 7 days of symptom onset. They were divided into different groups based on their subtypes according to TOAST criteria. In all the patients the plasma D-dimer levels were detected within 24 h of admission. Clinical neurological assessments were performed in line with National Institutes of Health Stroke Scale (NIHSS) once daily on the day of admission and on the 14th day. The outcome was evaluated by neurological improvement rate. Comparisons were made among the different subtypes based on the level of plasma D-dimer and the outcome. A total of 300 patients with acute ischemic stroke were included, 40 with cardioembolism; 47 with large-artery atherosclerosis; 143 with small-artery occlusion, 5 with other etiology stroke; and 65 with undetermined etiology stroke. The level of plasma D-dimer was negatively related to the outcome (r = -0.41; P = 0.013). Patients with cardioembolism had the highest level of plasma D-dimer and they suffered the most serious neurological deficit and the worst outcome among the five subtypes, the difference was statistically significant (F = 5.34; P = 0.012); while the lacunar stroke patients had the best outcome with the lowest level of D-dimer. High-level plasma D-dimer of acute period strongly indicates an unfavorable clinical outcome.

Correlation between Serum D-Dimer Level and Volume in Acute Ischemic Stroke

OBJECTIVE

D-dimer is a breakdown product of fibrin mesh after factor XIII stabilization. Previously, many authors have demonstrated a relationship between D-dimer level and stroke progression or type. This study aimed to investigate the relationship between D-dimer level and stroke volume.

METHODS

Between January 2008 and December 2009, we analyzed the D-dimer levels of 59 acute ischemic stroke patients in our neurosurgical department both upon admission and after seven days of initial treatment. Each patient's National Institute of Health Stroke Scale score, modified Rankin Scales score, Glasgow outcome score, and infarction volume were also evaluated.

RESULTS

Mean D-dimer level at admission was 626.6 µg/L (range, 77-4,752 µg/L) and the mean level measured after seven days of treatment was 238.3 µg/L (range, 50-924 µg/L). Mean D-dimer level at admission was 215.3 µg/L in patients with focal infarctions, 385.7 µg/L in patients with multiple embolic infarctions, 566.2 µg/L in those with 1-19 cc infarctions, 668.8 µg/L in 20-49 cc infarctions, 702.5 µg/L in 50-199 cc infarctions, and 844.0 µg/L in >200 cc infarctions (p=0.044). On the 7th day of treatment, the D-dimer levels had fallen to 201.0 µg/L, 293.2 µg/L, 272.0 µg/L, 232.8 µg/L, 336.6 µg/L, and 180.0 µg/L, respectively (p=0.530).

CONCLUSION

Our study shows that D-dimer level has the positive correlation with infarction volume and can be use to predict infarction-volume.

Changes in hemocoagulation in acute stroke patients after one-hour sono-thrombolysis using a diagnostic probe

The aim was to monitor the changes in hemocoagulation parameters in acute ischemic stroke (AIS) patients after sono-thrombolysis of the occluded middle cerebral artery using a duplex transcranial probe with 2.0-MHz frequency in Doppler mode. Sixteen AIS patients indicated for intravenous thrombolysis (IVT) (8 males; mean age 68.3 +/- 7.1 y) and 16 AIS patients contraindicated for IVT (11 males; mean age 67.9 +/- 7.9 y) were randomized for sono-thrombolysis (8 + 8 patients) or standard treatment (control group) (8 + 8 patients). The significant decrease of plasminogen activator inhibitor-1, plasminogen and alpha-2-antiplasmin activity by a mean of 60, 32 and 24%, respectively, and the increase of tissue plasminogen activator by a mean of 56% was found after sono-thrombolysis when compared with control group (p < 0.0125); these changes were more evident in patients treated with a combination of sono-thrombolysis and IVT (79, 38, 50 and 82%, respectively) than in patients treated by sono-thrombolysis alone (34, 13, 17 and 30%, respectively).

Sensitive and selective detection of free FXIII activation peptide: a potential marker of acute thrombotic events

Coagulation factor XIII (FXIII) stabilizes fibrin fibers and is therefore a major player in the maintenance of hemostasis. FXIII is activated by thrombin resulting in cleavage and release of the FXIII activation peptide (AP-FXIII). The objective of this study was to characterize the released AP-FXIII and determine specific features that may be used for its specific detection. We analyzed the structure of bound AP-FXIII within the FXIII A-subunit and interactions of AP-FXIII by hydrogen bonds with both FXIII A-subunit monomers. We optimized our previously developed AP-FXIII ELISA by using 2 monoclonal antibodies. We determined high binding affinities between the antibodies and free AP-FXIII and demonstrated specific binding by epitope mapping analyses with surface plasmon resonance and enzyme-linked immunosorbent assay. Because the structure of free AP-FXIII had been characterized so far by molecular modeling only, we performed structural analysis by nuclear magnetic resonance. Recombinant AP-FXIII was largely flexible both in plasma and water, differing significantly from the rigid structure in the bound state. We suggest that the recognized epitope is either occluded in the noncleaved form or possesses a structure that does not allow binding to the antibodies. On the basis of our findings, we propose AP-FXIII as a possible new marker for acute thrombotic events.