Admission Serum Calcium Level as a Prognostic Marker for Intracerebral Hemorrhage

Association between serum calcium level and the risk of acute kidney injury in ICU patients with subarachnoid hemorrhage: a retrospective cohort study

Aim

This study aimed to evaluate the association between serum calcium level and the risk of acute kidney injury (AKI) in patients with subarachnoid hemorrhage (SAH).

Methods

In this retrospective cohort study, data on adults from the Medical Information Mart for Intensive Care (MIMIC-III and MIMIC-IV) databases, spanning from 2008 to 2019, were extracted. In the logistic regression models, confounding variables, including age, white blood cell (WBC), systolic blood pressure (SBP), heart rate, blood urea nitrogen (BUN), glucose, international normalized ratio (INR), and the Charlson Comorbidity Index (CCI), were finally adjusted by stepwise regression. The outcome event was the occurrence of AKI after intensive care unit (ICU) admission. The univariate and multivariate logistic regression models were utilized to assess the association between serum calcium level and the risk of AKI in SAH patients, with odds ratios (ORs) and 95% confidence intervals (CIs). To further explore the association, subgroup analyses were performed, stratified by age, Glasgow Coma Scale (GCS) scores, drugs, and surgical methods.

Results

A total of 1,128 patients with SAH were included in the study, of which 457 patients developed AKI. Low levels of serum calcium were significantly associated with a high risk of AKI in patients with SAH, with an OR (95%CI) of 1.38 (1.01-1.89). Further subgroup analyses showed that low levels of calcium were significantly associated with a high risk of AKI in SAH patients aged ≥60 years (OR = 0.27, 95%CI: 0.09-0.83), who had GCS score ≥13 (OR = 1.57, 95%CI: 1.08-2.30), who did not use calcium channel blockers (CCB) (OR = 2.22, 95%CI: 1.16-4.25) and angiotensin-converting enzyme (ACE) inhibitors (OR = 1.51, 95%CI: 1.06-2.14), and who did not undergo aneurysm embolization (OR = 1.48, 95%CI: 1.01-2.17) and aneurysm clipping (OR = 1.45, 95%CI: 1.04-2.01).

Conclusion

The results of our study indicated that low levels of serum calcium were significantly associated with the risk of AKI in patients with SAH.

The Relationship Between Ionized Calcium Levels and Prognosis in Patients with Spontaneous Subarachnoid Hemorrhage

BACKGROUND

The serum calcium plays a role as a cofactor in critical steps such as cardiac contractility, vascular tone, and the coagulation cascade. This study aimed to determine if the level of ionized calcium can predict outcomes in patients with spontaneous subarachnoid hemorrhage (SAH) in the emergency department.

METHODS

The study was a retrospective cross-sectional case series. Patients aged 18 and over diagnosed with spontaneous SAH in the emergency department were included in the study. Patients' demographic characteristics, comorbidities, vital signs, laboratory parameters, World Federation of Neurosurgical Societies score, SAH grading according to the Fisher scale, needs of mechanical ventilation and inotropic treatment, administered treatments, complications, Rankin scores at discharge, and outcome were recorded in a standard data form.

RESULTS

A total of 267 patients were studied, with a mean age of 55.5 ± 13.4 years, and 53.9% (n = 144) were female. Hydrocephalus was present in 16.5% of patients. The average hospital stay was 20.4 ± 19.8 days. Mortality rate was 34.8% (n = 93). Mortality was significantly higher in patients with low calcium levels upon admission (P = 0.024). Ionized calcium levels during complication development independently predicted mortality (OR: 0.945, 95% CI: 0.898-0.996, P = 0.034). Patients with poor neurologic outcomes (Rankin: 3-6) had significantly lower initial ionized calcium levels (P = 0.002).

CONCLUSIONS

The ionized calcium level is a readily accessible blood gas parameter that assists clinicians in predicting functional independence and mortality at discharge in patients presenting to the emergency department with spontaneous SAH.

Can baseline serum calcium levels predict outcomes of intracerebral hemorrhage? A systematic review and meta-analysis

OBJECTIVE

The prognostic role of baseline calcium levels in patients with intracerebral hemorrhage (ICH) is conflicting. We aimed to conduct the first meta-analysis in the literature to examine if baseline calcium levels can predict outcomes after ICH.

METHODS

English-language studies listed on the databases of Embase, PubMed, ScienceDirect, and Web of Science were searched up to 20th November 2023. Meta-analysis was conducted for baseline hematoma volume, hematoma expansion, unfavorable functional outcome, and mortality.

RESULTS

Ten studies were included. Meta-analysis showed that patients with hypocalcemia have significantly higher baseline hematoma volume (MD: 8.6 95 % CI: 3.30, 13.90 I2 = 88 %) but did not have a higher risk of hematoma expansion (OR: 1.82 95 % CI: 0.89, 3.73 I2 = 82 %). Meta-analysis of crude (OR: 1.86 95 % CI: 1.25, 2.78 I2 = 63 %) and adjusted data (OR: 2.05 95 % CI: 1.27, 3.28 I2 = 64 %) showed those with hypocalcemia had a significantly higher risk of unfavorable functional outcomes. Meta-analysis of both crude (OR: 2.09 95 % CI: 1.51, 2.88 I2 = 80 %) and adjusted data (OR: 1.38 95 % CI: 1.14, 1.69 I2 = 70 %) also demonstrated a significantly higher risk of mortality in patients with hypocalcemia.

CONCLUSION

Baseline serum calcium may have a prognostic role in ICH. Hypocalcemia at baseline may lead to large hematoma volume and poor functional and survival outcomes. However, there seems to be no relation between hypocalcemia and the risk of hematoma expansion. Further studies examining the role of calcium on ICH prognosis are needed.

A Comparison of the Clinical Characteristics of Short-, Mid-, and Long-Term Mortality in Patients Attended by the Emergency Medical Services: An Observational Study

AIM

The development of predictive models for patients treated by emergency medical services (EMS) is on the rise in the emergency field. However, how these models evolve over time has not been studied. The objective of the present work is to compare the characteristics of patients who present mortality in the short, medium and long term, and to derive and validate a predictive model for each mortality time.

METHODS

A prospective multicenter study was conducted, which included adult patients with unselected acute illness who were treated by EMS. The primary outcome was noncumulative mortality from all causes by time windows including 30-day mortality, 31- to 180-day mortality, and 181- to 365-day mortality. Prehospital predictors included demographic variables, standard vital signs, prehospital laboratory tests, and comorbidities.

RESULTS

A total of 4830 patients were enrolled. The noncumulative mortalities at 30, 180, and 365 days were 10.8%, 6.6%, and 3.5%, respectively. The best predictive value was shown for 30-day mortality (AUC = 0.930; 95% CI: 0.919-0.940), followed by 180-day (AUC = 0.852; 95% CI: 0.832-0.871) and 365-day (AUC = 0.806; 95% CI: 0.778-0.833) mortality.

DISCUSSION

Rapid characterization of patients at risk of short-, medium-, or long-term mortality could help EMS to improve the treatment of patients suffering from acute illnesses.

Clinical features and associated factors of coexisting intracerebral hemorrhage in patients with cerebral small vessel disease: a cross-sectional study

Intracerebral hemorrhage (ICH) is generally considered to be closely related to cerebral small vessel disease (CSVD), leading to a poor prognosis. However, the coexistence of ICH in general CSVD patients and related factors remain underreported. In our cross-sectional study, we screened 414 CSVD patients from a database at the Department of Neurology, First Affiliated Hospital of Zhengzhou University (September 2018 to April 2022). Imaging biomarkers of CSVD and coexisting ICH lesion were assessed. Factors associated with coexisting ICH in CSVD were determined using multivariate logistic regression analysis. ICH was observed in 59 patients (14.3%). Multivariate logistic regression showed that previous history of ischemic stroke or transient ischemic attack (OR 5.189, 95%CI 2.572-10.467, P < 0.001), high-grade perivascular space in the basal ganglia (n > 10) (OR 2.051, 95%CI 1.044-4.027, P = 0.037) and low adjusted calcium-phosphorus product (OR 0.728 per 1 [mmol/L]2 increase, 95%CI 0.531-0.998, P = 0.049) were associated with coexisting ICH in CSVD patients. The considerable proportion of coexisting ICH and revelation of associated factors in general CSVD patients alert physicians of the potential risk of the reoccurrence of ICH, and might have a significant impact on therapeutic strategies.

Prognostic value of day-of-event serum calcium and magnesium for predicting 1-year prognosis after intracerebral hemorrhage

AIM

To investigate whether serum calcium and magnesium on the day of symptom onset contribute to prognosis at 1 year after intracerebral hemorrhage (ICH).

METHODS

We prospectively enrolled patients admitted < 24 h after symptom onset of primary ICH to West China Hospital between January 2012 and October 2014. Blood samples were collected at admission to determine the concentration of serum calcium and magnesium. We analyzed associations of the serum concentration of calcium and magnesium with unfavorable outcome (defined as modified Rankin scale, mRS ≥ 3) at 1 year.

RESULTS

We included 874 patients (mean age 59.1 ± 13.5 years, 67.6% males), of whom 470 patients had mRS ≥ 3 and 284 patients died at 1 year. Compared to patients with the highest tertile level of calcium concentration (≥ 2.29 mmol/L), patients in the lowest tertile (≤ 2.15 mmol/L) had higher odds of unfavorable outcome (odds ratio, OR 1.61, 95% confidence interval [CI] 1.04-2.50, P = 0.034). The Kaplan-Meier survival curve revealed a significant difference of cumulative survival rate across calcium tertiles (log-rank P value = 0.038). There was no significant association between serum concentration of magnesium and functional outcome at 1 year.

CONCLUSION

A reduced serum concentration of calcium on the day-of-event was associated with unfavorable outcome at 1 year after ICH. Future studies are needed to illustrate the pathophysiological mechanism of calcium and whether calcium could be a treatment target for improving outcomes after ICH.

Blood-Based Biomarkers in Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is one of the most lethal subtypes of stroke, associated with high morbidity and mortality. Prevention of hematoma growth and perihematomal edema expansion are promising therapeutic targets currently under investigation. Despite recent improvements in the management of ICH, the ideal treatments are still to be determined. Early stratification and triage of ICH patients enable the adjustment of the standard of care in keeping with the personalized medicine principles. In recent years, research efforts have been concentrated on the development and validation of blood-based biomarkers. The benefit of looking for blood candidate markers is obvious because of their acceptance in terms of sample collection by the general population compared to any other body fluid. Given their ease of accessibility in clinical practice, blood-based biomarkers have been widely used as potential diagnostic, predictive, and prognostic markers. This review identifies some relevant and potentially promising blood biomarkers for ICH. These blood-based markers are summarized by their roles in clinical practice. Well-designed and large-scale studies are required to validate the use of all these biomarkers in the future.

Association Between Admission Ionized Calcium Level and Neurological Outcome of Patients with Isolated Severe Traumatic Brain Injury: A Retrospective Cohort Study

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Pathophysiological processes following initial insult are complex and not fully understood. Ionized calcium (Ca++) is an essential cofactor in the coagulation cascade and platelet aggregation, and hypocalcemia may contribute to the progression of intracranial bleeding. On the other hand, Ca++ is an important mediator of cell damage after TBI and cellular hypocalcemia may have a neuroprotective effect after brain injury. We hypothesized that early hypocalcemia might have an adverse effect on the neurological outcome of patients suffering from isolated severe TBI. In this study, we aimed to evaluate the relationship between admission Ca++ level and the neurological outcome of these patients.

METHODS

This was a retrospective, single-center, cohort study of all patients admitted between January 2014 and December 2020 due to isolated severe TBI, which was defined as head abbreviated injury score ≥ 4 and an absence of severe (abbreviated injury score > 2) extracranial injuries. The primary outcome was a favorable neurological status at discharge, defined by a modified Rankin Scale of 0-2. Multivariable logistic regression was performed to determine whether admission hypocalcemia (Ca++  < 1.16 mmol L-1) is an independent predictor of neurological status at discharge.

RESULTS

The final analysis included 201 patients. Hypocalcemia was common among patients with isolated severe TBI (73.1%). Most of the patients had mild hypocalcemia (1 < Ca++  < 1.16 mmol L-1), and only 13 (6.5%) patients had Ca++  ≤ 1.00 mmol L-1. In the entire cohort, hypocalcemia was independently associated with higher rates of good neurological status at discharge (adjusted odds ratio of 3.03, 95% confidence interval 1.11-8.33, p = 0.03). In the subgroup of 81 patients with an admission Glasgow Coma Scale > 8, 52 (64.2%) had hypocalcemia. Good neurological status at discharge was recorded in 28 (53.8%) of hypocalcemic patients compared with 14 (17.2%) of those with normal Ca++ (p = 0.002). In multivariate analyses, hypocalcemia was independently associated with good neurological status at discharge (adjusted odds ratio of 6.67, 95% confidence interval 1.39-33.33, p = 0.02).

CONCLUSIONS

Our study demonstrates that among patients with isolated severe TBI, mild admission hypocalcemia is associated with better neurological status at hospital discharge. The prognostic value of Ca++ may be greater among patients with admission Glasgow Coma Scale > 8. Trials are needed to investigate the role of hypocalcemia in brain injury.

Low serum calcium is a novel predictor of unfavorable prognosis after traumatic brain injury

Background

Accurate and convenient serological markers for prognosis after traumatic brain injury (TBI) are still lacking. We aimed to explore the predictive value of serum calcium for prognosing outcomes within 6 months after TBI.

Methods

In this multicenter retrospective study, 1255 and 719 patients were included in development and validation cohorts, respectively, and their 6-month prognoses were recorded. Serum calcium was measured through routine blood tests within 24 h of hospital admission. Two multivariate predictive models with or without serum calcium for prognosis were developed. Receiver operating characteristics and calibration curves were applied to estimate their performance.

Results

The patients with lower serum calcium levels had a higher frequency of unfavorable 6-month prognosis than those without. Lower serum calcium level at admission was associated with an unfavorable 6-month prognosis in a wide spectrum of patients with TBI. Lower serum calcium level and our prognostic model including calcium performed well in predicting the 6-month unfavorable outcome. The calcium nomogram maintained excellent performance in discrimination and calibration in the external validation cohort.

Conclusions

Lower serum calcium level upon admission is an independent risk factor for an unfavorable 6-month prognosis after TBI. Integrating serum calcium into a multivariate predictive model improves the performance for predicting 6-month unfavorable outcomes.

Association of hypocalcemia with in-hospital mortality in critically ill patients with intracerebral hemorrhage: A retrospective cohort study

Background and purpose

There was little evidence to study the relationship between hypocalcemia and mortality among critically ill patients with intracerebral hemorrhage (ICH) aged ≥16 years. This study aimed to determine the potential association between hypocalcemia and in-hospital and ICU mortality in patients with ICH in the United States.

Methods

We analyzed 1,954 patients with ICH from the e-Intensive Care Unit Collaborative Research Database and divided them into hypocalcemia and non-hypocalcemia groups. Hypocalcemia was defined as albumin-adjusted total calcium below 8.4 mg/dl. The primary and secondary outcomes were hospital and ICU mortality, respectively. We performed multivariable regression and subgroup analyses to evaluate the association of hypocalcemia with hospital and ICU mortality. Cumulative survival rate analysis was performed using Kaplan-Meier curves with log-rank statistics.

Results

We enrolled 1,954 patients with ICH who had been hospitalized in ICU for >24 h and were older than 16 years (average age, 61.8 years; men, 56.7%). We noted that 373 (19%) hospital mortality occurred, including 235 (12%) ICU mortality. In this sample, 195 patients had hypocalcemia. Multivariable logistic regression analyses showed that hypocalcemia was associated with a 67% increased risk of in-hospital and a 72% increased risk of ICU mortality. This association was consistent across subgroup analyses.

Conclusions

Hypocalcemia was associated with a high risk of hospital and ICU mortality among critically ill patients with ICH. Future prospective, randomized, controlled studies are needed to confirm our results.

Early Prediction of Cerebral Computed Tomography under Intelligent Segmentation Algorithm Combined with Serological Indexes for Hematoma Enlargement after Intracerebral Hemorrhage

The aim of this study was to explore the application value of brain computed tomography (CT) images under intelligent segmentation algorithm and serological indexes in the early prediction of hematoma enlargement in patients with intracerebral hemorrhage (ICH). Fuzzy C-means (FCM) intelligence segmentation algorithm was introduced, and 150 patients with early ICH were selected as the research objects. Patient cerebral CT images were intelligently segmented to assess the diagnostic value of this algorithm. According to different hematoma volumes during CT examination, patients were divided into observation group (hematoma enlargement occurred, n = 48) and control group (no hematoma enlargement occurred, n = 102). The predicative value of hematoma enlargement after ICH was investigated by assessing CT image quality and measuring intracerebral edema, hematoma volume, and serological indicators of the patients of the two groups. The results demonstrated that the sensitivity, specificity, and accuracy of CT images processed by intelligence segmentation algorithm amounted to 0.894, 0.898, and 0.930, respectively. Besides, early edema enlargement and hematoma of patients in the observation group were more significant than those of patients in the control group. Relative edema volume was 0.912, which was apparently lower than that in the control group (1.017) (P < 0.05). In terms of CT signs of ICH patients, the incidence of blend sign, low density sign, and stroke of the observation group was evidently higher than those of the control group (P < 0.05). Besides, absolute lymphocyte count (ALC) and hemoglobin (HGB) concentration of the patients in the observation group were 6.23 × 109/L and 6.29 × 109/L, respectively, both of which were higher than those of the control group (6.08 × 109/L and 4.25 × 109/L). Neutrophil to lymphocyte ratio (NLR) was 0.99 × 109/L, which was apparently lower than that in the control group (1.43 × 109/L) (P < 0.05). To sum up, cerebral CT images processed by FCM algorithm showed good diagnostic effect on ICH and high clinical values in the early prediction of hematoma among ICH patients.

Association between serum calcium level and hemorrhagic progression in patients with traumatic intraparenchymal hemorrhage: Investigating the mediation and interaction effects of coagulopathy

In this study, we investigate the association of serum calcium with coagulopathy and hemorrhagic progression contusion (HPC) in patients with traumatic intraparenchymal hemorrhage (tIPH), and further explored the interaction and mediation effect between serum calcium as well as coagulopathy on HPC. Retrospective analyses of patients with tIPH admitted to the First Affiliated Hospital of Wenzhou Medical University between January 2016 to December 2019. The clinical data, coagulation parameters, and serum calcium levels were collected for further analysis. Multivariate logistic regression analysis was applied to identify the association of serum calcium level with coagulopathy and HPC. Causal mediation analysis (CMA) and additive interaction model were used to estimate the interaction and mediation effect between serum calcium as well as coagulopathy on HPC. Additionally, we repeated the analysis using corrected calcium. A total of 473 patients were included in this study. Of these, 54 (11.4%) patients had hypocalcemia at admission, 105 (22.2%) presented with coagulopathy, and 187 (39.5%) experienced HPC. Admission serum calcium level in patients presented with coagulopathy and HPC were 8.84 [IQR: 8.44-9.40] and 8.92 [IQR: 8.48-9.40] mg/dL respectively, which were significantly lower than that of patients without (9.10 [IQR: 8.68-9.88] and 9.12 [IQR: 8.72-9.89] mg/dL; all p < 0.001). Multivariate logistic regression analysis identified that hypocalcemia emerged as an independent risk factor for coagulopathy and HPC. However, no significant interaction was detected between hypocalcemia and coagulopathy. CMA showed that the mediator coagulopathy explained 24.4% (95% CI: 4.7-65.0%; p = 0.006) of the association between hypocalcemia and HPC. Moreover, comparable results were held using corrected calcium as well. Admission serum calcium level is associated with the HPC for patients with tIPH and this relationship is partially mediated by coagulopathy, but no significant interaction is detected. Further studies are needed to validate the findings and explore its mechanisms.

Elevated Red Cell Distribution Width to Platelet Ratio Is Associated With Poor Prognosis in Patients With Spontaneous, Deep-Seated Intracerebral Hemorrhage

Object: Inflammatory response is an important determinant of subsequent brain injury after deep-seated intracerebral hemorrhage (ICH). The ratio of red blood cell (RBC) distribution width to platelet count (RPR) has been established as a new index to reflect the severity of inflammation. To the best of our knowledge, no association between RPR and prognosis after spontaneous ICH has yet been reported.

Methods: In all patients with deep-seated ICH treated at our Neurovascular Center from 2014 to 2020, initial laboratory values were obtained to determine RPR in addition to patient characteristics and known risk factors. Subsequent multivariate analysis was performed to identify independent risk factors for 90-day mortality after deep-seated ICH.

Results: Hundred and two patients with deep-seated ICH were identified and further analyzed. Patients with an initial RPR < 0.06 exhibited significantly lower mortality rate after 90 days than those with an initial RPR ≥ 0.06 (27 vs. 57%; p = 0.003). Multivariate analysis identified “ICH score ≥ 3” (p = 0.001), “anemia on admission” (p = 0.01), and “elevated RPR ≥ 0.06” (p = 0.03) as independent predictors of 90-day mortality.

Conclusions: The present study constitutes the first attempt to demonstrate that the ratio of RBC distribution width to platelets—as an independent inflammatory marker—might serve for prognostic assessment in deep-seated ICH.

Association Between Ionized Calcium Level and Neurological Outcome in Endovascularly Treated Patients with Spontaneous Subarachnoid Hemorrhage: A Retrospective Cohort Study

BACKGROUND

Spontaneous subarachnoid hemorrhage (SSAH) is associated with significant morbidity and mortality. Pathophysiological processes following initial bleeding are complex and not fully understood. In this study, we aimed to determine whether a low level of ionized calcium (Ca⁺⁺), an essential cofactor in the coagulation cascade and other cellular processes, is associated with adverse neurological outcome, development of early hydrocephalus, and symptomatic vasospasm among patients with SSAH.

METHODS

This was a retrospective single-center cohort study of all patients admitted for SSAH between January 1, 2009, and April 31, 2020. The primary outcome was an unfavorable neurological status at discharge, defined as a modified Rankin Scale score greater than or equal to 3. Secondary outcomes were the development of early hydrocephalus and symptomatic vasospasm. Multivariable logistic regression was performed to determine whether Ca⁺⁺ was an independent predictor of these outcomes.

RESULTS

A total of 255 patients were included in the final analysis. Hypocalcemia, older age, admission Glasgow Coma Scale (GCS) score, and admission Hunt-Hess classification scale (H&H) grades IV and V were independently associated with unfavorable neurological outcome, with adjusted odds ratios (ORs) of 1.93 (95% confidence interval [CI] 1.1-3.4; p = 0.02) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level, 1.04 (95% CI 1.01-1.08; p = 0.02) for each year increase, 0.82 (95% CI 0.68-0.99; p = 0.04), and 6.29 (95% CI 1.14-34.6; p = 0.03), respectively. Risk factors for the development of hydrocephalus were hypocalcemia and GCS score, with ORs of 1.85 (95% CI 1.26-2.71; p = 0.002) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level and 0.83 (95% CI 0.73-0.94; p = 0.005), respectively. Ca⁺⁺ was not associated with symptomatic vasospasm (OR 1.04 [95% CI 0.76-1.41]; p = 0.81). Among patients with admission H&H grade I-III bleeding, hypocalcemia was independently associated with unfavorable neurological outcome at discharge, with an adjusted OR of 1.99 (95% CI 1.03-3.84; p = 0.04) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level. Hypocalcemia was also an independent risk factor for the development of early hydrocephalus, with an adjusted OR of 2.95 (95% CI 1.49-5.84; p = 0.002) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level. Ca⁺⁺ was not associated with symptomatic vasospasm. No association was found between Ca⁺⁺ and predefined outcomes among patients with admission H&H grade IV and V bleeding.

CONCLUSIONS

Our study shows that hypocalcemia is associated with worse neurological outcome at discharge and development of early hydrocephalus in endovascularly treated patients with SSAH. Potential mechanisms include calcium-induced coagulopathy and higher blood pressure. Trials are needed to assess whether correction of hypocalcemia will lead to improved outcomes.

Association between electrolyte levels at presentation and hematoma expansion and outcome in spontaneous intracerebral hemorrhage: A systematic review

PURPOSE

To assess the association between specific electrolyte levels (sodium, potassium, calcium, magnesium, and phosphorus) on presentation and hematoma expansion (HE) and outcome in intracerebral hemorrhage (ICH).

METHODS

This review was conducted in accordance with the PRISMA statement recommendations. Three databases were searched (Pubmed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale tool.

RESULTS

18 full-text articles were included in this systematic review including 10,385 ICH patients. Hypocalcemia was associated with worse short-term outcome in four studies, and two other studies were neutral. All studies investigating HE in hypocalcemia (n = 5) reported an association between low calcium level and HE. Hyponatremia (Na < 135 mEq/L) was shown to correlate with worse short-term outcome in two studies, and worse long-term outcome in one. There was one report showing no association between sodium level and HE. Hypomagnesemia was shown to be associated with worse short-term outcome in one study, while other reports were neutral. Studies evaluating hypophosphatemia or hypokalemia in ICH were limited, with no demonstrable significant effect on outcome.

CONCLUSION

This review suggests a significant association between hypocalcemia, hyponatremia and, of lesser degree, hypomagnesemia on admission and HE or worse outcome in ICH.

Blood Biomarkers for Stroke Diagnosis and Management

Biomarkers are objective indicators used to assess normal or pathological processes, evaluate responses to treatment and predict outcomes. Many blood biomarkers already guide decision-making in clinical practice. In stroke, the number of candidate biomarkers is constantly increasing. These biomarkers include proteins, ribonucleic acids, lipids or metabolites. Although biomarkers have the potential to improve the diagnosis and the management of patients with stroke, there is currently no marker that has demonstrated sufficient sensitivity, specificity, rapidity, precision, and cost-effectiveness to be used in the routine management of stroke, thus highlighting the need for additional work. A better standardization of clinical, laboratory and statistical procedures between centers is indispensable to optimize biomarker performance. This review focuses on blood biomarkers that have shown promise for translation into clinical practice and describes some newly reported markers that could add to routine stroke care. Avenues for the discovery of new stroke biomarkers and future research are discussed. The description of the biomarkers is organized according to their expected application in clinical practice: diagnosis, treatment decision, and outcome prediction.

Serum lipoprotein-associated phospholipase A2 as a promising prognostic biomarker in association with 90-day outcome of acute intracerebral hemorrhage

BACKGROUND

Lipoprotein-associated phospholipase A2 (Lp-PLA2) is reflective of vascular inflammation and plays a role in the pathophysiology of cerebrovascular disease. We determine usefulness of serum Lp-PLA2 as a prognostic biomarker for intracerebral hemorrhage (ICH).

METHODS

In this prospective, observational study, serum Lp-PLA2 concentrations were detected among 164 patients with acute spontaneous basal ganglia hemorrhage and 164 healthy controls. Using multivariate analysis, we analyzed its association with poor outcome (modified Rankin Scale >2) at poststroke 90 days and hemorrhagic severity indicated by National Institutes of Health Stroke Scale (NIHSS) score and hematoma volume.

RESULTS

Serum Lp-PLA2 concentrations were remarkably higher in patients than in controls. Lp-PLA2 concentrations were independently correlated with NIHSS score (t = 5.095, P < .001) and hematoma volume (t = 2.850, P = .005). At 90-day follow-up, 85 patients (51.8%) had poor outcome. Under receiver operating characteristic curve, serum Lp-PLA2 showed a significant prognostic discriminatory capability (AUC, 0.813; 95% CI, 0.744-0.869). Serum Lp-PLA2 concentrations ≥304 ng/ml was an independent predictor associated with poor outcome (OR 7.052; 95% CI 1.971-25.228).

CONCLUSIONS

Rising serum Lp-PLA2 concentrations are closely hemorrhagic severity and clinical outcomes after ICH, substantializing serum Lp-PLA2 as a potential prognostic biomarker of ICH.