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Marsool MDM, Prajjwal P, John J, Keluskar HS, Sivarajan VV, Kundiri KA, Lam JR, Chavda S, Atew HG, Marsool ADM, Hameed AAZ, Hussin OA. Association of multiple sclerosis with stroke: A comprehensive review. Health Sci Rep 2024; 7:e1837. [PMID: 38264155 PMCID: PMC10804671 DOI: 10.1002/hsr2.1837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/23/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024] Open
Abstract
Background Multiple sclerosis (MS) is a chronic immune-mediated disorder characterized by the degradation of the myelin sheath in the central nervous system. Research indicates that individuals with MS exhibit a higher susceptibility to stroke compared to the general population. This association is rooted in shared underlying mechanisms, specifically involving neuroinflammatory processes. Methodology We performed an extensive search on PubMed, MEDLINE, Embase, Scopus, and Google Scholar using specific terms. The search terms included variations of "multiple sclerosis," "stroke," "cerebrovascular disease," "vascular risk factors," "disease-modifying therapies," and "neuroinflammation." The search was limited to articles published from January 1, 2000, up to 31 May, 2023. Results and Discussion Stroke, a global health burden characterized by significant mortality and adult disability, underscores the critical importance of understanding the link between MS and stroke. Despite a growing body of research establishing an elevated risk of stroke in MS patients, notable information gaps persist. Limited prospective multicenter studies on stroke incidence in MS patients contribute to an incomplete understanding of the precise relationship between these two conditions. Conclusion In conclusion, this review underscores the critical need for a thorough understanding of the complex relationship between MS and stroke. The identified risk factors and the influence of MS DMTs on stroke risk necessitate further investigation to inform evidence-based preventive and therapeutic strategies. Bridging the existing information gaps through prospective multicenter studies is imperative for a comprehensive understanding of this association. The development of targeted diagnostic and therapeutic approaches for acute stroke risk in MS patients is paramount to mitigate the impact of these debilitating conditions. Ultimately, this review serves as a foundation for future efforts to enhance preventative measures and therapeutic interventions, thereby improving the overall quality of life for individuals with MS susceptible to strokes.
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Affiliation(s)
| | | | - Jobby John
- Internal MedicineDr. Somervell Memorial CSI Medical College and HospitalNeyyāttinkaraIndia
| | | | | | | | - Justin R. Lam
- Internal MedicineCebu Institute of MedicineCebuPhilippines
| | - Sachi Chavda
- Internal MedicineGMERS Medical College SolaAhmedabadIndia
| | - Hundaol G. Atew
- Internal MedicineSt Paul's Millennium Medical CollegeAddis AbabaEthiopia
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Shaheryar ZA, Khan MA, Hameed H, Mushtaq MN, Muhammad S, Shazly GA, Irfan A, Jardan YAB. Natural Fatty Acid Guards against Brain Endothelial Cell Death and Microvascular Pathology following Ischemic Insult in the Presence of Acute Hyperglycemia. Biomedicines 2023; 11:3342. [PMID: 38137563 PMCID: PMC10742291 DOI: 10.3390/biomedicines11123342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Ischemic stroke is worsened by the presence of sudden high blood sugar levels, even in individuals without pre-existing diabetes. This elevated glucose concentration hampers the ability of energy-starved brain cells to efficiently use it as a source of energy. Consequently, this leads to the production of abundant amounts of toxic glucose metabolites, which trigger oxidative stress in the brain milieu, particularly in the microvasculature of the brain. A prominent feature of this oxidative stress is the demise of endothelial cells, causing detrimental changes in blood vessels, including a reduction in their vascular diameter, a decreased efficiency of vessel proliferation, and the impaired integrity of tight junctions. These vascular pathologies contributed to an increase in the volume of damaged tissues (infarct), an exacerbation of brain swelling (edema), and a decline in cognitive and motor functions. In a mouse model of ischemic stroke with induced acute hyperglycemia, a naturally occurring saturated fatty acid provides protective cover to the microvasculature by preventing damage related to oxidative stress. Our current research revealed that lauric acid (LA) attenuated infarct volume and reduced brain edema by reducing endothelial cell death, enhancing vessels' diameter, promoting vascular angiogenesis, and stabilizing barrier functions. Animals administered with this natural compound showed a significant reduction in 4-HNE-positive vessels. In conclusion, natural saturated fatty acids help to preserve brain microvascular functions following ischemic insults in the presence of acute hyperglycemia.
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Affiliation(s)
| | - Mahtab Ahmad Khan
- Faculty of Pharmaceutical Sciences, University of Central Punjab (UCP), Lahore 54000, Pakistan
| | - Huma Hameed
- Faculty of Pharmaceutical Sciences, University of Central Punjab (UCP), Lahore 54000, Pakistan
| | | | - Sajjad Muhammad
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, FI-00029 Helsinki, Finland
- Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstrasse-5, 40225 Düsseldorf, Germany
| | - Gamal A. Shazly
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
| | - Ali Irfan
- Department of Chemistry, Government College University Faisalabad, Faisalabad 38000, Pakistan;
| | - Yousef A. Bin Jardan
- Department of Pharmaceutics, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
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3
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Doskas T, Dardiotis E, Vavougios GD, Ntoskas KT, Sionidou P, Vadikolias K. Stroke risk in multiple sclerosis: a critical appraisal of the literature. Int J Neurosci 2023; 133:1132-1152. [PMID: 35369835 DOI: 10.1080/00207454.2022.2056459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
Observational studies suggest that the occurrence of stroke on multiple sclerosis (MS) patients is higher compared to the general population. MS is a heterogeneous disease that involves an interplay of genetic, environmental and immune factors. The occurrence of stroke is subject to a wide range of both modifiable and non-modifiable, short- and long-term risk factors. Both MS and stroke share common risk factors. The immune mechanisms that underlie stroke are similar to neurodegenerative diseases and are attributed to neuroinflammation. The inflammation in autoimmune diseases may, therefore, predispose to an increased risk for stroke or potentiate the effect of conventional stroke risk factors. There are, however, additional determinants that contribute to a higher risk and incidence of stroke in MS. Due to the challenges that are associated with their differential diagnosis, the objective is to present an overview of the factors that may contribute to increased susceptibility or occurrence of stroke in MSpatients by performing a review of the available to date literature. As both MS and stroke can individually detrimentally affect the quality of life of afflicted patients, the identification of factors that contribute to an increased risk for stroke in MS is crucial for the prompt implementation of preventative therapeutic measures to limit the additive burden that stroke imposes.
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Affiliation(s)
- Triantafyllos Doskas
- Department of Neurology, Athens Naval Hospital, Athens, Greece
- Department of Neurology, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University Hospital of Larissa, Larissa, Greece
- Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Brinholi FF, Michelin AP, Matsumoto AK, de O Semeão L, Almulla AF, Supasitthumrong T, Tunvirachaisakul C, Barbosa DS, Maes M. Paraoxonase 1 status is a major Janus-faced component of mild and moderate acute ischemic stroke and consequent disabilities. Metab Brain Dis 2023; 38:2115-2131. [PMID: 37204661 DOI: 10.1007/s11011-023-01232-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023]
Abstract
AIMS This study aims to examine the associations between paraoxonase 1 (PON)1 status and acute ischemic stroke (AIS) and consequent disabilities. METHODS This study recruited 122 patients with AIS and 40 healthy controls and assessed the Q192R gene variants, arylesterase (AREase) and chloromethyl phenylacetate (CMPAase) activities, and high-density lipoprotein cholesterol (HDLc) in baseline conditions. AREase and CMPAase were measured 3 months later. The National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin score (mRS) were assessed at baseline and 3 and 6 months later. RESULTS Reduced CMPAase and increased AREase activities are significantly associated with AIS and mRS and NIHSS scores (baseline and 3 and 6 months later). The best predictor of AIS/disabilities was a decrease in the z-unit-based composite zCMPAase-zAREase score. Serum high density lipoprotein cholsterol (HDLc) was significantly correlated with CMPAase, but not AREase, activity and a lowered zCMPAase + zHDLc score was the second best predictor of AIS/disabilities. Regression analysis showed that 34.7% of the variance in baseline NIHSS was explained by zCMPAase-zAREase and zCMPAase + zHDLc composites, HDLc, and hypertension. Neural network analysis showed that stroke was differentiated from controls with an area under the ROC curve of 0.975 using both new composite scores, PON1 status, hypertension, dyslipidemia, previous stroke as body mass index. The PON1 Q192R genotype has many significant direct and mediated effects on AIS/disabilities, however, its overall effect was not significant. DISCUSSION PON1 status and the CMPAase-HDLc complex play key roles in AIS and its disabilities at baseline and 3 and 6 months later.
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Affiliation(s)
- Francis F Brinholi
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina, Brazil
| | - Ana Paula Michelin
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina, Brazil
| | - Andressa K Matsumoto
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina, Brazil
| | - Laura de O Semeão
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina, Brazil
| | - Abbas F Almulla
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok, 10330, Thailand
- Medical Laboratory Technology Department, College of Medical Technology, The Islamic University, Najaf, Iraq
| | - Thitiporn Supasitthumrong
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok, 10330, Thailand
| | - Chavit Tunvirachaisakul
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok, 10330, Thailand
| | - Décio S Barbosa
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina, Brazil
| | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok, 10330, Thailand.
- Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria.
- Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Korea.
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Pinzon RT, Wijaya VO, Veronica V. The role of homocysteine levels as a risk factor of ischemic stroke events: a systematic review and meta-analysis. Front Neurol 2023; 14:1144584. [PMID: 37251231 PMCID: PMC10216881 DOI: 10.3389/fneur.2023.1144584] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/07/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction Among numerous risk factors, homocysteine (Hcy) has been linked to cerebral infarction; however, results have been inconsistent. This review aimed to conduct a meta-analysis of published studies to investigate the relationship between plasma Hcy levels and the risk of ischemic stroke. Methods A systematic literature search was conducted until November 2022 to obtain articles reporting Hcy levels in ischemic stroke patients. Review Manager software was used to perform all statistical analyses (version 5.3). Results Initial investigation yielded 283 articles. The final evaluation included 21 articles, including two prospective studies, one retrospective cohort, and 18 case-control studies. These studies included 9888 participants, of which 5031 were admitted patients with ischemic stroke. An integrated analysis revealed that ischemic stroke patients had significantly higher levels of Hcy than controls (mean difference (MD) = +3.70, 95% confidence interval (CI) = 2.42-5.81, p < 0.001). Conclusion This meta-analysis and systematic review indicate that ischemic stroke patients have significantly higher homocysteine levels than controls. Detecting hyperhomocysteinemia and reducing homocysteine levels should be explored among individuals at increased risk for ischemic stroke.
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Affiliation(s)
- Rizaldy Taslim Pinzon
- Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia
- Neurology Department, Bethesda Hospital, Yogyakarta, Indonesia
| | | | - Vanessa Veronica
- Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia
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Maes M, Brinholi FF, Michelin AP, Matsumoto AK, de Oliveira Semeão L, Almulla AF, Supasitthumrong T, Tunvirachaisakul C, Barbosa DS. In Mild and Moderate Acute Ischemic Stroke, Increased Lipid Peroxidation and Lowered Antioxidant Defenses Are Strongly Associated with Disabilities and Final Stroke Core Volume. Antioxidants (Basel) 2023; 12:antiox12010188. [PMID: 36671047 PMCID: PMC9854933 DOI: 10.3390/antiox12010188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/06/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
In acute ischemic stroke (AIS), there are no data on whether oxidative stress biomarkers have effects above and beyond known risk factors and measurements of stroke volume. This study was conducted in 122 mild-moderate AIS patients and 40 controls and assessed the modified ranking scale (mRS) at baseline, and 3 and 6 months later. We measured lipid hydroperoxides (LOOH), malondialdehyde (MDA), advanced oxidation protein products, paraoxonase 1 (PON1) activities and PON1 Q192R genotypes, high density lipoprotein cholesterol (HDL), sulfhydryl (-SH) groups), and diffusion-weighted imaging (DWI) stroke volume and fluid-attenuated inversion recovery (FLAIR) signal intensity. We found that (a) AIS is characterized by lower chloromethyl acetate CMPAase PON1 activity, HDL and -SH groups and increased LOOH and neurotoxicity (a composite of LOOH, inflammatory markers and glycated hemoglobin); (b) oxidative and antioxidant biomarkers strongly and independently predict mRS scores 3 and 6 months later, DWI stroke volume and FLAIR signal intensity; and (c) the PON1 Q192R variant has multiple effects on stroke outcomes that are mediated by its effects on antioxidant defenses and lipid peroxidation. Lipid peroxidation and lowered -SH and PON1-HDL activity are drug targets to prevent AIS and consequent neurodegenerative processes and increased oxidative reperfusion mediators due to ischemia-reperfusion injury.
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Affiliation(s)
- Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok 10330, Thailand
- Cognitive Fitness and Technology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Department of Psychiatry, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria
- Research Institute, Medical University Plovdiv, 4000 Plovdiv, Bulgaria
- Deakin University, IMPACT-the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, VIC 3220, Australia
- Correspondence:
| | - Francis F. Brinholi
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
| | - Ana Paula Michelin
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
| | - Andressa K. Matsumoto
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
| | - Laura de Oliveira Semeão
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
| | - Abbas F. Almulla
- Medical Laboratory Technology Department, College of Medical Technology, The Islamic University, Najaf 54001, Iraq
| | - Thitiporn Supasitthumrong
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok 10330, Thailand
| | - Chavit Tunvirachaisakul
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok 10330, Thailand
| | - Decio S. Barbosa
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
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7
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Monsour M, Gordon J, Lockard G, Borlongan CV. Stem Cells Attenuate the Inflammation Crosstalk Between Ischemic Stroke and Multiple Sclerosis: A Review. Cell Transplant 2023; 32:9636897231184596. [PMID: 37515536 PMCID: PMC10387781 DOI: 10.1177/09636897231184596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/06/2023] [Accepted: 06/11/2023] [Indexed: 07/31/2023] Open
Abstract
The immense neuroinflammation induced by multiple sclerosis (MS) promotes a favorable environment for ischemic stroke (IS) development, making IS a deadly complication of MS. The overlapping inflammation in MS and IS is a prelude to the vascular pathology, and an inherent cell death mechanism that exacerbates neurovascular unit (NVU) impairment in the disease progression. Despite this consequence, no therapies focus on reducing IS incidence in patients with MS. To this end, the preclinical and clinical evidence we review here argues for cell-based regenerative medicine that will augment the NVU dysfunction and inflammation to ameliorate IS risk.
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Affiliation(s)
- Molly Monsour
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jonah Gordon
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Gavin Lockard
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Cesar V Borlongan
- Center of Excellence for Aging & Brain Repair, Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Need for a Paradigm Shift in the Treatment of Ischemic Stroke: The Blood-Brain Barrier. Int J Mol Sci 2022; 23:ijms23169486. [PMID: 36012745 PMCID: PMC9409167 DOI: 10.3390/ijms23169486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/04/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022] Open
Abstract
Blood-brain barrier (BBB) integrity is essential to maintaining brain health. Aging-related alterations could lead to chronic progressive leakiness of the BBB, which is directly correlated with cerebrovascular diseases. Indeed, the BBB breakdown during acute ischemic stroke is critical. It remains unclear, however, whether BBB dysfunction is one of the first events that leads to brain disease or a down-stream consequence. This review will focus on the BBB dysfunction associated with cerebrovascular disease. An added difficulty is its association with the deleterious or reparative effect, which depends on the stroke phase. We will first outline the BBB structure and function. Then, we will focus on the spatiotemporal chronic, slow, and progressive BBB alteration related to ischemic stroke. Finally, we will propose a new perspective on preventive therapeutic strategies associated with brain aging based on targeting specific components of the BBB. Understanding BBB age-evolutions will be beneficial for new drug development and the identification of the best performance window times. This could have a direct impact on clinical translation and personalised medicine.
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9
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Protein Biomarkers in Blood Reflect the Interrelationships Between Stroke Outcome, Inflammation, Coagulation, Adhesion, Senescence and Cancer. Cell Mol Neurobiol 2022; 43:1413-1424. [PMID: 35953740 PMCID: PMC9371377 DOI: 10.1007/s10571-022-01260-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 07/08/2022] [Indexed: 11/11/2022]
Abstract
The most important predictors for outcomes after ischemic stroke, that is, for health deterioration and death, are chronological age and stroke severity; gender, genetics and lifestyle/environmental factors also play a role. Of all these, only the latter can be influenced after the event. Recurrent stroke may be prevented by antiaggregant/anticoagulant therapy, angioplasty of high-grade stenoses, and treatment of cardiovascular risk factors. Blood cell composition and protein biomarkers such as C-reactive protein or interleukins in serum are frequently considered as biomarkers of outcome. Here we aim to provide an up-to-date protein biomarker signature that allows a maximum of mechanistic understanding, to predict health deterioration following stroke. We thus surveyed protein biomarkers that were reported to be predictive for outcome after ischemic stroke, specifically considering biomarkers that predict long-term outcome (≥ 3 months) and that are measured over the first days following the event. We classified the protein biomarkers as immune‑inflammatory, coagulation-related, and adhesion-related biomarkers. Some of these biomarkers are closely related to cellular senescence and, in particular, to the inflammatory processes that can be triggered by senescent cells. Moreover, the processes that underlie inflammation, hypercoagulation and cellular senescence connect stroke to cancer, and biomarkers of cancer-associated thromboembolism, as well as of sarcopenia, overlap strongly with the biomarkers discussed here. Finally, we demonstrate that most of the outcome-predicting protein biomarkers form a close-meshed functional interaction network, suggesting that the outcome after stroke is partially determined by an interplay of molecular processes relating to inflammation, coagulation, cell adhesion and cellular senescence.
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10
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Liu Y, Zhao J, Li F, Sun H, Sun Y, Sun H, Yang F, Zhao Y, Liang Z, Tang Y. Predictive value of hemoglobin level on early neurological outcomes in acute ischemic stroke. Neurol Res 2022; 44:684-691. [PMID: 35130819 DOI: 10.1080/01616412.2022.2035621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Few studies have examined the association between hemoglobin (Hb) levels and early neurological changes following acute ischemic stroke (AIS). The present research investigated whether higher or lower Hb level on admission was associated with early neurological deterioration (END) in AIS patients. Furthermore, we evaluated the predictive effect of Hb concentration on stable or improving outcome. METHODS In this prospective cohort study, a total of 1330 patients admitted within 24 hours after AIS onset were finally involved in the analysis. We classified participants into four groups according to baseline Hb levels: ≤120, 121-140, 141-160, and >160 g/L. The risk of END was accessed by means of logistic regression analysis, and tendency of improvement and stability by multinomial logit analysis. We further evaluated the pattern and magnitude of association of Hb as a continuous variable and END by multivariate logistic regression analysis of restricted cubic spline. RESULTS Compared with the reference group, hemoglobin >160 g/L was associated with END (OR, 95%CI; 2.149, 1.314-3.512) and severe END (OR, 95% CI as 2.317, 1.351-3.976 and 2.810,1.589-4.968, respectively). Comparatively, higher Hb level also independently predicted improving (OR, 95% CI; 0.322, 0.170-0.609) and stable (OR, 95% CI; 0.371, 0.205-0.673) outcome. Similar results were found when restricted to anterior circulation ischemic stroke after adjustment of variables including large vessel disease. CONCLUSIONS We concluded that patients with higher baseline Hb level are at significantly higher risk for END, and less likely to reach stable or improving status at the early stage of stroke.
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Affiliation(s)
- Yue Liu
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Jingbo Zhao
- Department of Epidemiology, School of Public Health, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Fang Li
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Hongwei Sun
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yanyan Sun
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Hongwei Sun
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Fan Yang
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yu Zhao
- Department of Laboratory Diagnosis, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Zijun Liang
- Department of Health Insurance Management, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Ying Tang
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
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11
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Li Y, Lu J, Wang J, Deng P, Meng C, Tang H. Inflammatory Cytokines and Risk of Ischemic Stroke: A Mendelian Randomization Study. Front Pharmacol 2022; 12:779899. [PMID: 35111052 PMCID: PMC8801801 DOI: 10.3389/fphar.2021.779899] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/06/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Observational studies have revealed the association between some inflammatory cytokines and the occurrence of ischemic stroke, but the causal relationships remain unclear. Methods: We conducted a two-sample Mendelian randomization (MR) analysis to assess the causal effects of thirty inflammatory cytokines and the risk of ischemic stroke. For exposure data, we collected genetic variants associated with inflammatory cytokines as instrumental variables (IVs) from a genome-wide association study (GWAS) meta-analysis from Finland (sample size up to 8,293). For the outcome data, we collected summary data of ischemic stroke from a large-scale GWAS meta-analysis involved 17 studies (34,217 cases and 406,111 controls). We further performed a series of sensitivity analyses as validation of primary MR results. Results: According to the primary MR estimations and further sensitivity analyses, we established one robust association after Bonferroni correction: the odds ratio (95% CI) per unit change in genetically increased IL-4 was 0.84 (0.89–0.95) for ischemic stroke. The chemokine MCP3 showed a nominally significant association with ischemic stroke risk (OR: 0.93, 95% CI: 0.88–0.99, unadjusted p < 0.05). There was no evidence of a causal effect of other inflammatory cytokines and the risk of ischemic stroke. Conclusions: Our study suggested that genetically increased IL-4 levels showed a protective effect on the risk of ischemic stroke, which provides important new insights into the potential therapeutic target for preventing ischemic stroke.
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Affiliation(s)
- Yalan Li
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China.,Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Jun Lu
- School of Medicine, Hunan Normal University, Changsha, China
| | - Jie Wang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China.,Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Peizhi Deng
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China.,Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Changjiang Meng
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, China.,Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Haibo Tang
- Department of Metabolic and Bariatric Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
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12
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Kieran NW, Suresh R, Dorion MF, MacDonald A, Blain M, Wen D, Fuh SC, Ryan F, Diaz RJ, Stratton JA, Ludwin SK, Sonnen JA, Antel J, Healy LM. MicroRNA-210 regulates the metabolic and inflammatory status of primary human astrocytes. J Neuroinflammation 2022; 19:10. [PMID: 34991629 PMCID: PMC8740343 DOI: 10.1186/s12974-021-02373-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Astrocytes are the most numerous glial cell type with important roles in maintaining homeostasis and responding to diseases in the brain. Astrocyte function is subject to modulation by microRNAs (miRs), which are short nucleotide strands that regulate protein expression in a post-transcriptional manner. Understanding the miR expression profile of astrocytes in disease settings provides insight into the cellular stresses present in the microenvironment and may uncover pathways of therapeutic interest.
Methods Laser-capture microdissection was used to isolate human astrocytes surrounding stroke lesions and those from neurological control tissue. Astrocytic miR expression profiles were examined using quantitative reverse transcription polymerase chain reaction (RT-qPCR). Primary human fetal astrocytes were cultured under in vitro stress conditions and transfection of a miR mimic was used to better understand how altered levels of miR-210 affect astrocyte function. The astrocytic response to stress was studied using qPCR, enzyme-linked immunosorbent assays (ELISAs), measurement of released lactate, and Seahorse. Results Here, we measured miR expression levels in astrocytes around human ischemic stroke lesions and observed differential expression of miR-210 in chronic stroke astrocytes compared to astrocytes from neurological control tissue. We also identified increased expression of miR-210 in mouse white matter tissue around middle cerebral artery occlusion (MCAO) brain lesions. We aimed to understand the role of miR-210 in primary human fetal astrocytes by developing an in vitro assay of hypoxic, metabolic, and inflammatory stresses. A combination of hypoxic and inflammatory stresses was observed to upregulate miR-210 expression. Transfection with miR-210-mimic (210M) increased glycolysis, enhanced lactate export, and promoted an anti-inflammatory transcriptional and translational signature in astrocytes. Additionally, 210M transfection resulted in decreased expression of complement 3 (C3) and semaphorin 5b (Sema5b). Conclusions We conclude that miR-210 expression in human astrocytes is modulated in response to ischemic stroke disease and under in vitro stress conditions, supporting a role for miR-210 in the astrocytic response to disease conditions. Further, the anti-inflammatory and pro-glycolytic impact of miR-210 on astrocytes makes it a potential candidate for further research as a neuroprotective agent. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-021-02373-y.
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Affiliation(s)
- Nicholas W Kieran
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Rahul Suresh
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Marie-France Dorion
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Adam MacDonald
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Manon Blain
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Dingke Wen
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Shih-Chieh Fuh
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Fari Ryan
- Centre for Research in Neuroscience, The Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Roberto J Diaz
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Jo Anne Stratton
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Samuel K Ludwin
- Department of Pathology, Queen's University, Kingston, ON, Canada
| | - Joshua A Sonnen
- Departments of Pathology, Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Jack Antel
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Luke M Healy
- Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC, Canada.
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13
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Li J, Huang J, Pang T, Chen Z, Li J, Wu L, Hu Y, Chen W. Risk Estimation of Infectious and Inflammatory Disorders in Hospitalized Patients With Acute Ischemic Stroke Using Clinical-Lab Nomogram. Front Neurol 2021; 12:710144. [PMID: 34956037 PMCID: PMC8702498 DOI: 10.3389/fneur.2021.710144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/30/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Infections after acute ischemic stroke are common and likely to complicate the clinical course and negatively affect patient outcomes. Despite the development of various risk factors and predictive models for infectious and inflammatory disorders (IAID) after stroke, more objective and easily obtainable predictors remain necessary. This study involves the development and validation of an accessible, accurate nomogram for predicting in-hospital IAID in patients with acute ischemic stroke (AIS). Methods: A retrospective cohort of 2,257 patients with AIS confirmed by neurological examination and radiography was assessed. The International Statistical Classification of Diseases and Health related Problem's definition was used for IAID. Data was obtained from two hospitals between January 2016 and March 2020. Results: The incidence of IAID was 19.8 and 20.8% in the derivation and validation cohorts, respectively. Using an absolute shrinkage and selection operator (LASSO) algorithm, four biochemical blood predictors and four clinical indicators were optimized from fifty-five features. Using a multivariable analysis, four predictors, namely age (adjusted odds ratio, 1.05; 95% confidence interval [CI], 1.038–1.062; p < 0.001), comatose state (28.033[4.706–536.403], p = 0.002), diabetes (0.417[0.27–0.649], p < 0.001), and congestive heart failure (CHF) (5.488[2.451–12.912], p < 0.001) were found to be risk factors for IAID. Furthermore, neutrophil, monocyte, hemoglobin, and high-sensitivity C-reactive protein were also found to be independently associated with IAID. Consequently, a reliable clinical-lab nomogram was constructed to predict IAID in our study (C-index value = 0.83). The results of the ROC analysis were consistent with the calibration curve analysis. The decision curve demonstrated that the clinical-lab model added more net benefit than either the lab-score or clinical models in differentiating IAID from AIS patients. Conclusions: The clinical-lab nomogram predicted IAID in patients with acute ischemic stroke. As a result, this nomogram can be used for identification of high-risk patients and to further guide clinical decisions.
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Affiliation(s)
- Junhong Li
- Department of Neurology, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Jingjing Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Tingting Pang
- Guangxi University of Chinese Medicine, Nanning, China
| | - Zikun Chen
- Guangxi University of Chinese Medicine, Nanning, China
| | - Jing Li
- Guangxi University of Chinese Medicine, Nanning, China
| | - Lin Wu
- Department of Neurology, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Yuqiang Hu
- Department of Neurology, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Wei Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
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Lehmann ALCF, Alfieri DF, de Araújo MCM, Trevisani ER, Nagao MR, Pesente FS, Gelinski JR, de Freitas LB, Flauzino T, Lehmann MF, Lozovoy MAB, Breganó JW, Simão ANC, Maes M, Reiche EMV. Carotid intima media thickness measurements coupled with stroke severity strongly predict short-term outcome in patients with acute ischemic stroke: a machine learning study. Metab Brain Dis 2021; 36:1747-1761. [PMID: 34347209 DOI: 10.1007/s11011-021-00784-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 06/14/2021] [Indexed: 12/24/2022]
Abstract
Acute ischemic stroke (IS) is one of the leading causes of morbidity, functional disability and mortality worldwide. The objective was to evaluate IS risk factors and imaging variables as predictors of short-term disability and mortality in IS. Consecutive 106 IS patients were enrolled. We examined the accuracy of IS severity using the National Institutes of Health Stroke Scale (NIHSS), carotid intima-media thickness (cIMT) and carotid stenosis (both assessed using ultrasonography with doppler) predicting IS outcome assessed with the modified Rankin scale (mRS) three months after hospital admission. Poor prognosis (mRS ≥ 3) at three months was predicted by carotid stenosis (≥ 50%), type 2 diabetes mellitus and NIHSS with an accuracy of 85.2% (sensitivity: 90.2%; specificity: 81.8%). The mRS score at three months was strongly predicted by NIHSS (β = 0.709, p < 0.001). Short-term mortality was strongly predicted using a neural network model with cIMT (≥ 1.0 mm versus < 1.0 mm), NIHSS and age, yielding an area under the receiving operator characteristic curve of 0.977 and an accuracy of 94.7% (sensitivity: 100.0%; specificity: 90.9%). High NIHSS (≥ 15) and cIMT (≥ 1.0 mm) increased the probability of dying with hazard ratios of 7.62 and 3.23, respectively. Baseline NIHSS was significantly predicted by the combined effects of age, large artery atherosclerosis stroke, sex, cIMT, body mass index, and smoking. In conclusion, high values of cIMT and NIHSS at admission strongly predict short-term functional impairment as well as mortality three months after IS, underscoring the importance of those measurements to predict clinical IS outcome.
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Affiliation(s)
- Ana Lucia Cruz Fürstenberger Lehmann
- Department of Clinical Medicine, Health Sciences Center and Radiology Service, The University Hospital, State University of Londrina, Paraná, Brazil
| | - Daniela Frizon Alfieri
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil
| | | | - Emanuelle Roberto Trevisani
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil
| | - Maisa Rocha Nagao
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil
| | | | - Jair Roberto Gelinski
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil
| | - Leonardo Bodner de Freitas
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil
| | - Tamires Flauzino
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil
| | - Márcio Francisco Lehmann
- Department of Clinical Surgery, Health Sciences Center, Neurosurgery Service of the University Hospital, State University of Londrina, Paraná, Brazil
| | - Marcell Alysson Batisti Lozovoy
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil
- Department of Pathology, Clinical Analysis, and Toxicology, Health Sciences Center, State University of Londrina, Av. Robert Koch, 60, Paraná, CEP 86.038-440, Brazil
| | - José Wander Breganó
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil
- Department of Pathology, Clinical Analysis, and Toxicology, Health Sciences Center, State University of Londrina, Av. Robert Koch, 60, Paraná, CEP 86.038-440, Brazil
| | - Andréa Name Colado Simão
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil
- Department of Pathology, Clinical Analysis, and Toxicology, Health Sciences Center, State University of Londrina, Av. Robert Koch, 60, Paraná, CEP 86.038-440, Brazil
| | - Michael Maes
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia
- Department of Psychiatry, King Chulalongkorn Memorial Hospital, Chulalongkorn, Bangkok, Thailand
| | - Edna Maria Vissoci Reiche
- Laboratory of Research in Applied Immunology, Health Sciences Center, State University of Londrina, Paraná, Brazil.
- Department of Pathology, Clinical Analysis, and Toxicology, Health Sciences Center, State University of Londrina, Av. Robert Koch, 60, Paraná, CEP 86.038-440, Brazil.
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15
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Huang S, Cai J, Tian Y. The Prognostic Value of Homocysteine in Acute Ischemic Stroke Patients: A Systematic Review and Meta-Analysis. Front Syst Neurosci 2021; 14:600582. [PMID: 33643003 PMCID: PMC7907516 DOI: 10.3389/fnsys.2020.600582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/21/2020] [Indexed: 12/26/2022] Open
Abstract
Background: This comprehensive meta-analysis aimed to assess whether an increased homocysteine (Hcy) level is an independent predictor of unfavorable outcomes in acute ischemic stroke (AIS) patients. Methods: A comprehensive literature search was conducted up to August 1, 2020 to collect studies reporting Hcy levels in AIS patients. We analyzed all the data using Review Manager 5.3 software. Results: Seventeen studies with 15,636 AIS patients were selected for evaluation. A higher Hcy level was associated with a poorer survival outcome (OR 1.43, 95% CI: 1.25–1.63). Compared with the AIS group, Hcy levels were significantly lower in the healthy control patients, with an SMD of 5.11 and 95% CI (1.87–8.35). Analysis of the different subgroups of AIS demonstrated significant associations between high Hcy levels and survival outcomes only in Caucasian and Asian patients. Moreover, whereas high Hcy levels were closely associated with gender, B12 deficiency, smoking, and patients who received tissue plasminogen activator treatment, no significant difference was found between increased Hcy levels and age, drinking, hypertension, diabetes mellitus, and hyperlipidemia. In addition, the cut-off value (20.0 μmol/L) might be an optimum cut-off index for AIS patients in clinical practice. Conclusion: This meta-analysis reveals that the Hcy level may serve as an independent predictor for unfavorable survival outcomes in AIS patients, particularly in Caucasian and Asian AIS patients. Further studies can be conducted to clarify this relationship.
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Affiliation(s)
- Shengming Huang
- Department of Neurology, Luohe Central Hospital, The First Affiliated Hospital of Luohe Medical College, Luohe, China
| | - Jirui Cai
- Department of Cardiology, Luohe Central Hospital, The First Affiliated Hospital of Luohe Medical College, Luohe, China
| | - Yuejun Tian
- Department of Neurology, Luohe Central Hospital, The First Affiliated Hospital of Luohe Medical College, Luohe, China.,Institute of Urology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
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16
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Ertl M, Meisinger C, Linseisen J, Baumeister SE, Zickler P, Naumann M. Long-Term Outcomes in Patients with Stroke after in-Hospital Treatment-Study Protocol of the Prospective Stroke Cohort Augsburg (SCHANA Study). ACTA ACUST UNITED AC 2020; 56:medicina56060280. [PMID: 32517235 PMCID: PMC7353873 DOI: 10.3390/medicina56060280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION In Germany, stroke is the third leading cause of death, with more than 60,000 fatalities out of approximately 260,000 cases (first-ever and recurrent strokes) each year. So far, there are only a few long-term studies investigating determinants of the natural course of the disease, especially in the era of mechanical thrombectomy. MATERIALS AND METHODS The prospective single-center stroke cohort Augsburg (SCHANA) study will include about 1000 patients treated for stroke in the University Hospital of Augsburg. Patients aged 18 years or older with a confirmed diagnosis of ischemic or hemorrhagic stroke are included in the study. Information on demographic characteristics, onset of symptoms, etiologic factors, comorbidities, quality of life, invasive and non-invasive treatment, complications, and laboratory parameters are collected during a personal interview conducted during the patients' hospital stay and via a medical chart review. About 30 mL of blood is collected from each patient, and after processing and aliquoting, all blood specimens are frozen at -80° C. The study participants will be followed-up via postal questionnaires at three and 12 months after discharge from the hospital. Furthermore, mortality follow-ups will be conducted. Cox-regression analysis will be used to estimate relative risks. CONCLUSION The SCHANA study will generate comprehensive data on the long-term course of the disease. In addition to the main outcomes, recurrent events and survival, patient-oriented outcomes such as health-related quality of life and depression are the focus of the study.
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Affiliation(s)
- Michael Ertl
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (P.Z.); (M.N.)
- Correspondence: ; Tel.: +49-821-400-2991
| | - Christa Meisinger
- Independent Research Group Clinical Epidemiology, Helmholtz Zentrum München, Ingolstädter Landstr. 1, 85764 Neuherberg, Germany; (C.M.); (J.L.); (S.-E.B.)
- Chair of Epidemiology, Ludwig-Maximilians-Universität München, UNIKA-T Augsburg, Neusässer Str. 47, 86156 Augsburg, Germany
| | - Jakob Linseisen
- Independent Research Group Clinical Epidemiology, Helmholtz Zentrum München, Ingolstädter Landstr. 1, 85764 Neuherberg, Germany; (C.M.); (J.L.); (S.-E.B.)
- Chair of Epidemiology, Ludwig-Maximilians-Universität München, UNIKA-T Augsburg, Neusässer Str. 47, 86156 Augsburg, Germany
| | - Sebastian-Edgar Baumeister
- Independent Research Group Clinical Epidemiology, Helmholtz Zentrum München, Ingolstädter Landstr. 1, 85764 Neuherberg, Germany; (C.M.); (J.L.); (S.-E.B.)
| | - Philipp Zickler
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (P.Z.); (M.N.)
| | - Markus Naumann
- Department of Neurology and Clinical Neurophysiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (P.Z.); (M.N.)
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