Comparison of plasma copeptin and multiple biomarkers for assessing prognosis of patients with aneurysmal subarachnoid hemorrhage

Longitudinal change of serum AIM2 levels after aneurysmal subarachnoid hemorrhage and its prognostic significance: a two-center prospective cohort study

Absent in melanoma 2 (AIM2) is implicated in neuroinflammation. Here, we explored the prognostic significance of serum AIM2 in human aneurysmal subarachnoid hemorrhage (aSAH). We conducted a consecutive enrollment of 127 patients, 56 of whom agreed with blood-drawings not only at admission but also at days 1, 2, 3, 5, 7 and 10 days after aSAH. Serum AIM2 levels of patients and 56 healthy controls were measured. Disease severity was assessed using the modified Fisher scale (mFisher) and World Federation of Neurological Surgeons Scale (WFNS). Neurological outcome at poststroke 90 days was evaluated via the modified Rankin Scale (mRS). Univariate analysis and multivariate analysis were sequentially done to ascertain relationship between serum AIM2 levels, severity, delayed cerebral ischemia (DCI) and 90-day poor prognosis (mRS scores of 3-6). Patients, in comparison to controls, had a significant elevation of serum AIM2 levels at admission and at days 1, 2, 3, 5, 7 and 10 days after aSAH, with the highest levels at days 1, 2, 3 and 5. AIM2 levels were independently correlated with WFNS scores and mFisher scores. Significantly higher serum AIM2 levels were detected in patients with a poor prognosis than in those with a good prognosis, as well as in patients with DCI than in those without DCI. Moreover, serum AIM2 levels independently predicted a poor prognosis and DCI, and were linearly correlated with their risks. Using subgroup analysis, there were no significant interactions between serum AIM2 levels and age, gender, hypertension and so on. There were substantially high predictive abilities of serum AIM2 for poor prognosis and DCI under the receiver operating characteristic curve. The combination models of DCI and poor prognosis, in which serum AIM2, WFNS scores and mFisher scores were incorporated, showed higher discriminatory efficiencies than anyone of the preceding three variables. Moreover, the models are delineated using the nomogram, and performed well under the calibration curve and decision curve. Serum AIM2 levels, with a substantial enhancement during early phase after aSAH, are closely related to bleeding severity, poor 90-day prognosis and DCI of patients, substantializing serum AIM2 as a potential prognostic biomarker of aSAH.

GFAP and UCHL1 in Non-traumatic SAH: The Story thus Far. A Systematic Review of the Literature

OBJECTIVE

Non-traumatic subarachnoid hemorrhage (SAH) is associated with a high percentage of misdiagnosis and poor prognosis. Biomarkers could be useful in the identification, treatment/management guidance, and outcome improvement of SAH patients. The current systematic review aims to investigate the potential role of biomarkers GFAP (Glial Fibrillary Acidic Protein) and UCH-L1 (Ubiquitin C-Terminal Hydrolase L1) in the diagnosis and prognosis of non-traumatic SAH.

METHODS

A systematic search of PubMed, Scopus, and Web of Science databases was conducted from their inception through February 2023.

RESULTS

17 studies met the inclusion criteria and were included in this review. The vast majority of the included studies (82%) were on GFAP. Most studies used blood and/or CSF samples and incorporated multiple measurements through the initial hospitalization days. The majority of identified studies reported significantly higher levels of GFAP and UCHL1 in SAH patients with poor outcomes. There was notable variation in the specimen type and the timing of sampling.

CONCLUSION

Quantification of GFAP and UCHL1 through the initial days of hospitalization shows promise in the prediction of SAH patient outcomes. Further research is nevertheless warranted to confirm these findings and further clarify the use of the two biomarkers in SAH diagnosis and the prediction of severity and secondary events.

Usability of serum inter-α-trypsin inhibitor heavy chain 4 as a biomarker for assessing severity and predicting functional outcome after human aneurysmal subarachnoid hemorrhage: A prospective observational cohort study at a single institution

BACKGROUND

Inter-α-trypsin inhibitor heavy chain 4 (ITIH4) may harbor anti-inflammatory activities. We sought to discern the predictive significance of serum ITIH4 for delayed cerebral ischemia (DCI) and clinical outcomes of human aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

At a single institution, we performed a prospective and observational cohort study of 148 patients with aSAH and 52 healthy controls. Poststroke six-month extended Glasgow Outcome Scale (GOSE) score of 1-4 was designated as a poor prognosis. Prognosis associations were verified using multivariate analysis.

RESULTS

As compared to controls, patients had significantly declined serum ITIH4 concentrations from admission until day 10, with the lowest concentrations at days 1-3 after stroke. Serum ITIH4 concentrations, which were substantially decreased with the increasing Hunt-Hess scores or modified Fisher scores, were independently correlated with the two scores. Moreover, serum ITIH4 concentrations, which were markedly elevated in the order of GOSE scores from 1 to 8, together with Hunt-Hess scores and modified Fisher scores were independently related to GOSE scores and poor prognosis. However, serum ITIH4 concentrations were not independently predictive of DCI. Prediction model of poor prognosis integrating the preceding three variables were delineated using the nomogram, were verified under the calibration curve, and displayed high discriminatory efficiencies under the receiver operating characteristic curve.

CONCLUSIONS

A significant decline of serum ITIH4 concentrations during the early phase after aSAH was closely related to severity and poor prognosis, assuming that serum ITIH4 may represent a promising prognostic biomarker of aSAH.

Clinical potential of automated convolutional neural network-based hematoma volumetry after aneurysmal subarachnoid hemorrhage

OBJECTIVES

Cerebrospinal fluid hemoglobin has been positioned as a potential biomarker and drug target for aneurysmal subarachnoid hemorrhage-related secondary brain injury (SAH-SBI). The maximum amount of hemoglobin, which may be released into the cerebrospinal fluid, is defined by the initial subarachnoid hematoma volume (ISHV). In patients without external ventricular or lumbar drain, there remains an unmet clinical need to predict the risk for SAH-SBI. The aim of this study was to explore automated segmentation of ISHV as a potential surrogate for cerebrospinal fluid hemoglobin to predict SAH-SBI.

METHODS

This study is based on a retrospective analysis of imaging and clinical data from 220 consecutive patients with aneurysmal subarachnoid hemorrhage collected over a five-year period. 127 annotated initial non-contrast CT scans were used to train and test a convolutional neural network to automatically segment the ISHV in the remaining cohort. Performance was reported in terms of Dice score and intraclass correlation. We characterized the associations between ISHV and baseline cohort characteristics, SAH-SBI, ventriculoperitoneal shunt dependence, functional outcome, and survival. Established clinical (World Federation of Neurosurgical Societies, Hunt & Hess) and radiological (modified Fisher, Barrow Neurological Institute) scores served as references.

RESULTS

A strong volume agreement (0.73 Dice, range 0.43 - 0.93) and intraclass correlation (0.89, 95% CI, 0.81-0.94) were shown. While ISHV was not associated with the use of antithrombotics or cardiovascular risk factors, there was strong evidence for an association with a lower Glasgow Coma Scale at hospital admission. Aneurysm size and location were not associated with ISHV, but the presence of intracerebral or intraventricular hemorrhage were independently associated with higher ISHV. Despite strong evidence for a positive association between ISHV and SAH-SBI, the discriminatory ability of ISHV for SAH-SBI was insufficient. The discriminatory ability of ISHV was, however, higher regarding ventriculoperitoneal shunt dependence and functional outcome at three-months follow-up. Multivariate survival analysis provided strong evidence for an independent negative association between survival probability and both ISHV and intraventricular hemorrhage.

CONCLUSIONS

The proposed algorithm demonstrates strong performance in volumetric segmentation of the ISHV on the admission CT. While the discriminatory ability of ISHV for SAH-SBI was similar to established clinical and radiological scores, it showed a high discriminatory ability for ventriculoperitoneal shunt dependence and functional outcome at three-months follow-up.

Blood-Based Biomarkers for Neuroprognostication in Acute Brain Injury

Acute brain injury causes loss of functionality in patients that often is devastating. Predicting the degree of functional loss and overall prognosis requires a multifaceted approach to help patients, and more so their families, make important decisions regarding plans and goals of care. A variety of blood-based markers have been studied as one aspect of this determination. In this review, we discuss CNS-derived and systemic markers that have been studied for neuroprognostication purposes. We discuss the foundation of each protein, the conditions in which it has been studied, and how the literature has used these markers for interpretation. We also discuss challenges to using each marker in each section as well.

Serum Sestrin2 Emerges as a Prognostic Biomarker of Human Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Cohort Single-Center Study

Background

Sestrin2 functions as a neuroprotective factor. Herein, serum sestrin2 was investigated with respect to its associations with severity, delayed cerebral ischemia (DCI) and prognosis of aneurysmal subarachnoid hemorrhage (aSAH).

Methods

In this prospective, observational, cohort, single-center study, serum sestrin2 levels were measured at entry into the study in 45 healthy controls and at admission in 135 aSAH patients. Also, they were gauged in other time points (namely, at days 1, 2, 3, 5 and 7) among 45 patients. Unfavorable prognosis was defined as extended Glasgow Outcome Scale (GOSE) scores of 1-4 at six months after aSAH.

Results

Serum sestrin2 levels were immediately raised at admission in patients, increased thereafter, peaked at day 2, declined afterwards till day 7, and were significantly higher than those in controls (all P<0.001). Serum sestrin2 levels had independent correlation with Hunt-Hess scores (beta, 1.715; 95% confidence interval (CI), 0.595-2.835; P=0.003) and modified Fisher scores (beta, 2.505; 95% CI, 1.102-3.907; P=0.001). Alternatively, serum sestrin2 levels, which were independently correlated with 6-month GOSE scores (beta, -0.050; 95% CI, -0.099-0.001; P=0.044), were independently associated with DCI (odds ratio, 1.079; 95% CI, 1.008-1.156; P=0.029) and unfavorable prognosis (odds ratio, 1.093; 95% CI, 1.020-1.172; P=0.012). DCI and prognosis prediction models, which were composed of serum sestrin2, Hunt-Hess scores and modified Fisher scores, were comparatively stable and clinically beneficial under calibration curve and decision curve. Prognosis prediction model showed significantly higher area under receiver operating characteristic curve than serum sestrin2, Hunt-Hess scores and modified Fisher scores alone (all P<0.05).

Conclusion

A significant enhancement of serum sestrin2 levels after aSAH is independently related to severity, DCI and poor prognosis following aSAH. The models incorporating serum sestrin2 perform well in predicting the DCI and prognosis of aSAH patients. Presumably, determination of serum sestrin2 may be of clinical significance in aSAH.

The Role of Early Serum Biomarkers and Clinical Rating Scales in the Prediction of Delayed Cerebral Ischaemia and Short-Term Outcome after Aneurysmal Subarachnoid Haemorrhage: Single Centre Experience

Considering the variety of complications that arise after aneurysmal subarachnoid haemorrhage (aSAH) and the complex pathomechanism of delayed cerebral ischaemia (DCI), the task of predicting the outcome assumes a profound complexity. Therefore, there is a need to develop early predictive and decision-making models. This study explores the effect of serum biomarkers and clinical scales on patients' outcomes and their interrelationship with DCI and systemic complications in aSAH. This was a retrospective analysis including aSAH patients admitted to the Wroclaw University Hospital (Wrocław, Poland) from 2011 to 2020. A good outcome was defined as a modified Rankin Scale (mRS) score of 0-2. The prediction of the development of DCI and poor outcome was conducted using logistic regression as a standard model (SM) and random forest as a machine learning method (ML). A cohort of 174 aSAH patients were included in the analysis. DCI was diagnosed in 79 (45%) patients. Significant differences between patients with poor vs. good outcome were determined from their levels of albumin (31 ± 7 vs. 35 ± 5 (g/L); p < 0.001), D-dimer (3.0 ± 4.5 vs. 1.5 ± 2.8 (ng/mL); p < 0.001), procalcitonin (0.2 ± 0.4 vs. 0.1 ± 0.1 (ng/mL); p < 0.001), and glucose (169 ± 69 vs. 137 ± 48 (nmol/L); p < 0.001). SM for DCI prediction included the Apache II scale (odds ratio [OD] 1.05; 95% confidence interval [CI] 1.00-1.09) and albumin level (OD 0.88; CI 0.82-0.95). ML demonstrated that low albumin level, high Apache II scale, increased D-dimer and procalcitonin levels had the highest predictive values for DCI. The integration of clinical parameters and scales with a panel of biomarkers may effectively facilitate the stratification of aSAH patients, identifying those at high risk of secondary complications and poor outcome.

Biomarkers in aneurysmal subarachnoid hemorrhage: A short review

Poor outcomes of aneurysmal subarachnoid hemorrhage (aSAH) can be the result of the initial catastrophic event or the many acute or delayed neurological complications. Recent evidence suggests that some molecules play a critical role in both events, through some unknown pathways involved. Understanding the role of these molecules in these events could allow to improve diagnostic accuracy, guide management, and prevent long-term disability in aSAH. Here we present the studies on aSAH biomarkers present in current medical literature, highlighting their roles and main results.

Copeptin Implementation on Stroke Prognosis

Predicting functional outcome following stroke is considered to be of key importance in an attempt to optimize overall stroke care. Although clinical prognostic tools have been widely implemented, optimal blood biomarkers might be able to yield additional information regarding each stroke survivor's propensity for recovery. Copeptin seems to have interesting prognostic potential poststroke. The present review aims to explore the prognostic significance of copeptin in stroke patients. Literature research of two databases (MEDLINE and Scopus) was conducted to trace all relevant studies published between 16 February 2012 and 16 February 2022 that focused on the utility of copeptin as a prognostic marker in acute stroke setting. 25 studies have been identified and included in the present review. The predictive ability of copeptin regarding both functional outcome and mortality appears to be in the range of established clinical variables, thus highlighting the added value of copeptin evaluation in stroke management. Apart from acute ischemic stroke, the discriminatory accuracy of the biomarker was also demonstrated among patients with transient ischemic attack, intracerebral hemorrhage, and subarachnoid hemorrhage. Overall, copeptin represents a powerful prognostic tool, the clinical implementation of which is expected to significantly facilitate the individualized management of stroke patients.

Serum GFAP - reference interval and preanalytical properties in Danish adults

OBJECTIVES

Glial fibrillary acidic protein (GFAP) is a promising biomarker that could potentially contribute to diagnosis and prognosis in neurological diseases. The biomarker is approaching clinical use but the reference interval for serum GFAP remains to be established, and knowledge about the effect of preanalytical factors is also limited.

METHODS

Serum samples from 371 apparently healthy reference subjects, 21-90 years of age, were measured by a single-molecule array (Simoa) assay. Continuous reference intervals were modelled using non-parametric quantile regression and compared with traditional age-partitioned non-parametric reference intervals established according to the Clinical and Laboratory Standards Institute (CLSI) guideline C28-A3. The following preanalytical conditions were also examined: stability in whole blood at room temperature (RT), stability in serum at RT and -20 °C, repeated freeze-thaw cycles, and haemolysis.

RESULTS

The continuous reference interval showed good overall agreement with the traditional age-partitioned reference intervals of 25-136 ng/L, 34-242 ng/L, and 5-438 ng/L for the age groups 20-39, 40-64, and 65-90 years, respectively. Both types of reference intervals showed increasing levels and variability of serum GFAP with age. In the preanalytical tests, the mean changes from baseline were 2.3% (95% CI: -2.4%, 6.9%) in whole blood after 9 h at RT, 3.1% (95% CI: -4.5%, 10.7%) in serum after 7 days at RT, 10.4% (95% CI: -6.0%, 26.8%) in serum after 133 days at -20 °C, and 10.4% (95% CI: 9.5%, 11.4%) after three freeze-thaw cycles.

CONCLUSIONS

The study establishes age-dependent reference ranges for serum GFAP in adults and demonstrates overall good stability of the biomarker.

Copeptin as a Diagnostic and Prognostic Biomarker in Cardiovascular Diseases

Copeptin is the carboxyl-terminus of the arginine vasopressin (AVP) precursor peptide. The main physiological functions of AVP are fluid and osmotic balance, cardiovascular homeostasis, and regulation of endocrine stress response. Copeptin, which is released in an equimolar mode with AVP from the neurohypophysis, has emerged as a stable and simple-to-measure surrogate marker of AVP and has displayed enormous potential in clinical practice. Cardiovascular disease (CVD) is currently recognized as a primary threat to the health of the population worldwide, and thus, rapid and effective approaches to identify individuals that are at high risk of, or have already developed CVD are required. Copeptin is a diagnostic and prognostic biomarker in CVD, including the rapid rule-out of acute myocardial infarction (AMI), mortality prediction in heart failure (HF), and stroke. This review summarizes and discusses the value of copeptin in the diagnosis, discrimination, and prognosis of CVD (AMI, HF, and stroke), as well as the caveats and prospects for the application of this potential biomarker.

C-Terminal Proarginine Vasopressin is Associated with Disease Outcome and Mortality, but not with Delayed Cerebral Ischemia in Critically Ill Patients with an Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is an important indication for intensive care unit admission and may lead to significant morbidity and mortality. We assessed the ability of C-terminal proarginine vasopressin (CT-proAVP) to predict disease outcome, mortality, and delayed cerebral ischemia (DCI) in critically ill patients with aSAH compared with the World Federation of Neurological Surgeons (WFNS) score and Acute Physiological and Chronic Health Evaluation IV (APACHE IV) model.

METHODS

C-terminal proarginine vasopressin was collected on admission in this single-center, prospective, observational cohort study. The primary aim was to investigate the relationship between CT-proAVP and poor functional outcome at 1 year (Glasgow Outcome Scale score 1-3) in a multivariable logistic regression model adjusted for WFNS and APACHE IV scores. Secondary aims were mortality and DCI. The multivariable logistic regression model for DCI was also adjusted for the modified Fisher scale.

RESULTS

In 100 patients, the median CT-proAVP level was 24.9 pmol/L (interquartile range 11.5-53.8); 45 patients had a poor 1-year functional outcome, 19 patients died within 30 days, 25 patients died within 1 year, and DCI occurred in 28 patients. Receiver operating characteristics curves revealed high accuracy for CT-proAVP to identify patients with poor 1-year functional outcome (area under the curve [AUC] 0.84, 95% confidence interval [CI] 0.77-0.92, p < 0.001), 30-day mortality (AUC 0.84, 95% CI 0.76-0.93, p < 0.001), and 1-year mortality (AUC 0.79, 95% CI 0.69-0.89, p < 0.001). CT-proAVP had a low AUC for identifying patients with DCI (AUC 0.67, 95% CI 0.55-0.79, p 0.008). CT-proAVP ≥ 24.9 pmo/L proved to be a significant predictor for poor 1-year functional outcome (odds ratio [OR] 8.04, 95% CI 2.97-21.75, p < 0.001), and CT-proAVP ≥ 29.1 pmol/L and ≥ 27.7 pmol/L were significant predictors for 30-day and 1-year mortality (OR 9.31, 95% CI 1.55-56.07, p 0.015 and OR 5.15, 95% CI 1.48-17.93, p 0.010) in multivariable models with WFNS and APACHE IV scores. CT-proAVP ≥ 29.5 pmol/L was not a significant predictor for DCI in a multivariable model adjusted for the modified Fisher scale (p = 0.061).

CONCLUSIONS

C-terminal proarginine vasopressin was able to predict poor functional outcome and mortality in critically ill patients with aSAH. Its prognostic ability to predict DCI was low.

TRIAL REGISTRATION

Nederlands Trial Register: NTR4118.

Blood GFAP as an emerging biomarker in brain and spinal cord disorders

Blood-derived biomarkers for brain and spinal cord diseases are urgently needed. The introduction of highly sensitive immunoassays led to a rapid increase in the number of potential blood-derived biomarkers for diagnosis and monitoring of neurological disorders. In 2018, the FDA authorized a blood test for clinical use in the evaluation of mild traumatic brain injury (TBI). The test measures levels of the astrocytic intermediate filament glial fibrillary acidic protein (GFAP) and neuroaxonal marker ubiquitin carboxy-terminal hydrolase L1. In TBI, blood GFAP levels are correlated with clinical severity and extent of intracranial pathology. Evidence also indicates that blood GFAP levels hold the potential to reflect, and might enable prediction of, worsening of disability in individuals with progressive multiple sclerosis. A growing body of evidence suggests that blood GFAP levels can be used to detect even subtle injury to the CNS. Most importantly, the successful completion of the ongoing validation of point-of-care platforms for blood GFAP might ameliorate the decision algorithms for acute neurological diseases, such as TBI and stroke, with important economic implications. In this Review, we provide a systematic overview of the evidence regarding the utility of blood GFAP as a biomarker in neurological diseases. We propose a model for GFAP concentration dynamics in different conditions and discuss the limitations that hamper the widespread use of GFAP in the clinical setting. In our opinion, the clinical use of blood GFAP measurements has the potential to contribute to accelerated diagnosis and improved prognostication, and represents an important step forward in the era of precision medicine.

Copeptin and insulin-like growth factor-1 predict long-term outcomes after aneurysmal subarachnoid hemorrhage: A large prospective cohort study

OBJECTIVE

The predictive roles of copeptin and insulin-like growth factor-1 (IGF-1) in aneurysmal subarachnoid hemorrhage (aSAH) remain controversial. We aimed to define the relationship between copeptin and IGF-1 levels and functional outcome as well as quality of life (QoL) after aSAH.

METHODS

Patients with aSAH were prospectively enrolled in a tertiary university hospital. Controls were sex- and age-matched healthy subjects. Plasma concentrations of copeptin and IGF-1 were measured on admission. Demographics and clinical, radiological and laboratory characteristics of the patients were collected. Favorable functional outcome was defined as modified Rankins≤2, and QoL was evaluated by the 36-Item Short Form Health Survey (SF-36) 1 year after aSAH. Uni- and multivariable analyses were performed.

RESULTS

One hundred eighteen patients were eligible, with 122 healthy controls were included in this study. Plasma copeptin levels were significantly higher and plasma IGF-1 was lower in patients than in controls. Both copeptin (adjusted HR 4.143 [1.120-15.328], p = 0.033) and IGF-1 levels (adjusted HR 0.089 [0.013-0.602], p = 0.013) were positively associated with 1-year mortality, while only single copeptin and IGF-1 concentrations were independent predictors of poor functional outcome and QoL, respectively.

CONCLUSIONS

Plasma copeptin and IGF-1 levels are abnormal in patients with acute aSAH, and this may reliably predict long-term mortality, functional outcome and QoL.

Serum biomarkers and cerebral autoregulation as early warnings of delayed cerebral ischemia risk in patients after aneurysmal subarachnoid haemorrhage

BACKGROUND

Identifying patients at risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) remains challenging. This study aimed to evaluate the concentration of serum biomarkers along with cerebral autoregulation impairment on DCI.

METHODS

55 patients suffering from aSAH were enrolled in the study. Serum S100protein B (S100B) was tested both on the day of admission and over three consecutive days following the occurrence of aSAH. Cerebral autoregulation was assessed using a tissue oxygenation index (TOxa) based on near-infrared spectroscopy.

RESULTS

Changes in serum S100B levels interacted with DCI status (presence vs. absence): F = 3.84, p = 0.016. Patients with DCI had higher S100B concentration level on day 3 than those without DCI (3.54 ± 0.50 ng/ml vs. 0.58 ± 0.43 ng/ml, p = 0.001). S100B concentration on day 3 following aSAH predicted DCI (AUC = 0.77, p = 0.006). Raised level of serum S100B on day 3 was related with higher TOxa, thus with impaired cerebral autoregulation (r_S = 0.52,p = 0.031). Multivariate logistic regression analysis showed thatimpaired cerebral autoregulation andelevatedS100B concentration on day 3 increasethe likelihood of DCI.

CONCLUSIONS

Tracking changes in the serum biomarkers concentration along with monitoring of cerebral autoregulation, may play a role in early detection of patients at risk of DCI after aSAH. These results need to be validated in larger prospective cohorts.

The Role of Consecutive Plasma Copeptin Levels in the Screening of Delayed Cerebral Ischemia in Poor-Grade Subarachnoid Hemorrhage

The prognostic value of copeptin in subarachnoid hemorrhage (SAH) has been reported, but the prognosis was largely affected by the initial clinical severity. Thus, the previous studies are not very useful in predicting delayed cerebral ischemia (DCI) in poor-grade SAH patients. Here, we first investigated the feasibility of predicting DCI in poor-grade SAH based on consecutive measurements of plasma copeptin. We measured copeptin levels of 86 patients on days 1, 3, 5, 7, 9, 11, and 13 using ELISA. The primary outcome was the association between consecutive copeptin levels and DCI development. The secondary outcomes were comparison of copeptin with C-reactive protein (CRP) in predicting DCI. Additionally, we compared the prognostic value of transcranial Doppler ultrasonography (TCD) with copeptin using TCD alone to predict DCI. Increased copeptin (OR = 1.022, 95% CI: 1.008–1.037) and modified Fisher scale IV (OR = 2.841; 95% CI: 0.998–8.084) were closely related to DCI. Consecutive plasma copeptin measurements showed significant differences between DCI and non-DCI groups (p < 0.001). Higher CRP and DCI appeared to show a correlation, but it was not statistically significant. Analysis of copeptin changes with TCD appeared to predict DCI better than TCD alone with AUCROC differences of 0.072. Consecutive measurements of plasma copeptin levels facilitate the screening of DCI in poor-grade SAH patients.

Biomarkers of Neurological Outcome After Aneurysmal Subarachnoid Hemorrhage as Early Predictors at Discharge from an Intensive Care Unit

Background

Subarachnoid bleeding is associated with brain injuries and ranges from almost negligible to acute and life threatening. The main objectives were to study changes in brain-specific biomarker levels in patients after an aneurysmal subarachnoid hemorrhage (aSAH) in relation to early clinical findings, severity scores, and intensive care unit (ICU) outcome. Analysis was done to identify specific biomarkers as predictors of a bad outcome in the acute treatment phase.

Methods

Analysis was performed for the proteins of neurofilament, neuron-specific enolase (NSE), microtubule-associated protein tau (MAPT), and for the proteins of glial cells, S100B, and glial fibrillary acidic protein (GFAP). Outcomes were assessed at discharge from the ICU and analyzed based on the grade in the Glasgow Outcome Scale (GOS). Patients were classified into two groups: with a good outcome (Group 1: GOS IV–V, n = 24) and with a bad outcome (Group 2: GOS I–III, n = 31). Blood samples were taken upon admission to the ICU and afterward daily for up to 6 days.

Results

In Group 1, the level of S100B (1.0, 0.9, 0.7, 2.0, 1.0, 0.3 ng/mL) and NSE (1.5, 2.0, 1.6, 1.2, 16.6, 2.2 ng/mL) was significantly lower than in Group 2 (S100B: 4.7, 4.8, 4.4, 4.5, 6.6, 6.8 ng/mL; NSE: 4.0, 4.1, 4.3, 3.8, 4.4, 2.5 1.1 ng/mL) on day 1–6, respectively. MAPT was significantly lower only on the first and second day (83.2 ± 25.1, 132.7 ± 88.1 pg/mL in Group 1 vs. 625.0 ± 250.7, 616.4 ± 391.6 pg/mL in Group 2). GFAP was elevated in both groups from day 1 to 6. In the ROC analysis, S100B showed the highest ability to predict bad ICU outcome of the four biomarkers measured on admission [area under the curve (AUC) 0.81; 95% CI 0.67–0.94, p < 0.001]. NSE and MAPT also had significant predictive value (AUC 0.71; 95% CI 0.54–0.87, p = 0.01; AUC 0.74; 95% CI 0.55–0.92, p = 0.01, respectively). A strong negative correlation between the GOS and S100B and the GOS and NSE was recorded on days 1–5, and between the GOS and MAPT on day 1.

Conclusion

Our findings provide evidence that brain biomarkers such as S100B, NSE, GFAP, and MAPT increase significantly in patients following aSAH. There is a direct relationship between the neurological outcome in the acute treatment phase and the levels of S100B, NSE, and MAPT. The detection of brain-specific biomarkers in conjunction with clinical data may constitute a valuable diagnostic and prognostic tool in the early phase of aSAH treatment.

Osteopontin in the Cerebrospinal Fluid of Patients with Severe Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. In SAH patients, plasma osteopontin (OPN) has been shown to independently predict poor outcome. The aim of the study is to investigate, in a selected population with severe SAH, OPN time course in cerebrospinal fluid (CSF) and plasma during the first week after aneurism rupture, and OPN prognostic value. We included 44 patients with the following criteria: (1) age 18 and 80 years, (2) diagnosis of SAH from cerebral aneurysm rupture, (3) insertion of external ventricular drain. Plasma and CSF were sampled at day 1, 4, and 8. OPN levels, in CSF and plasma, displayed a weak correlation on day 1 and were higher, in CSF, in all time points. Only in poor prognosis patients, OPN levels in CSF significantly increased at day 4 and day 8. Plasma OPN at day 1 and 4 was predictor of poor outcome. In conclusion, plasma and CSF OPN displays a weak correlation, on day 1. The higher levels of OPN found in the CSF compared to plasma, suggest OPN production within the CNS after SAH. Furthermore, plasma OPN, at day 1 and 4, seems to be an independent predictor of poor outcome.

Prognostic value of copeptin in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Recently, copeptin has been identified as a plasma prognosis marker in acute ischemic stroke and intracerebral hemorrhage (ICH). This study investigated the prognostic value of copeptin in the patients with aneurysmal subarachnoid hemorrhage(aSAH).

METHODS

In this retrospective study, 243 consecutive patients were included. Upon admission, plasma copeptin levels were measured by enzyme-linked immunosorbent assay. The end points were mortality and poor functional outcome (Glasgow Outcome Scale score of 1-3) after 3 months.

RESULTS

In 243 patients, 112 (46.1%) were male and median age was 58 years (IQR 49-68). Median copeptin plasma levels were 21.0 pmol/l (IQR 13.2-31.2). Copeptin levels increased with increasing severity of aSAH as defined by the World Federation of Neurological Surgeons (WFNS) score. Patients with a poor outcome and nonsurvivors had significantly increased copeptin levels on admission (P < .001 both). In the multivariate analysis, for each 1 pmol/l increase of plasma concentration of copeptin, the adjusted risk of poor outcomes and mortality would be increased by and 6% (1.06 [1.02-1.10], P < .001) and 9% (1.09 [1.03-1.13], P < .001), respectively. Receiver operating characteristics to predict functional outcome and mortality demonstrated areas under the curve of copeptin of 0.74 (95% confidence interval [CI], 0.67-0.81) and 0.81 (95% CI, 0.74-0.87), which was comparable with the WFNS score(P > .05) but superior to C-reactive protein and IL-6 (P < .01).

CONCLUSIONS

The data shows that copeptin levels may reliably predict short-term prognosis at its onset in aSAH patients.

Clinical relevance of cleaved RAGE plasma levels as a biomarker of disease severity and functional outcome in aneurysmal subarachnoid hemorrhage

BACKGROUND

Cleaved receptor for advanced glycation end-products (cRAGE) has been introduced as a new inflammatory marker. We clarified the associations between cRAGE levels, disease severity and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

In this prospective, observational study, plasma levels of total soluble RAGE (sRAGE) and endogenous secretory RAGE (esRAGE) were quantified in 108 aSAH patients and 108 controls. The level of cRAGE was calculated by subtracting the level of esRAGE from that of sRAGE. World Federation of Neurological Surgeons (WFNS) score, modified Fisher score, and Hunt Hess (HH) score were recorded to assess aSAH severity. Relationship between plasma cRAGE levels and 6-month poor outcome (Glasgow Outcome Scale score of 1-3) was assess using multivariate analysis.

RESULTS

Plasma cRAGE levels were significantly higher in patients than in controls. Its levels were significantly correlated with WNFS score, modified Fisher score and HH score of patients. Plasma cRAGE emerged as an independent predictor for 6-month poor outcome. Area under receiver operating characteristic curve (AUC) of this biomarker was similar to those of WNFS score, modified Fisher score and HH score. Moreover, it significantly improved AUCs of WNFS score, modified Fisher score and HH score.

CONCLUSIONS

Plasma cRAGE levels are highly associated with the severity and poor prognosis in aSAH.

Increased serum interleukin-33 concentrations predict worse prognosis of aneurysmal subarachnoid hemorrhage

BACKGROUND

Interleukin-33 (IL-33) is an inflammatory biomarker. We elucidated the relationship between serum IL-33 concentrations, severity and prognosis in aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We prospectively recruited 175 controls and 175 aSAH patients. Serum IL-33 concentrations were gauged using an enzyme-linked immunosorbent assay. Clinical and radiological severity was assessed by World Federation of Neurological Surgeons (WFNS) scale and modified Fisher grading scale respectively. Poor outcome was defined as Glasgow Outcome Scale score of 1-3.

RESULTS

Serum IL-33 concentrations were significantly higher in patients than in controls. IL-33 concentrations were significantly increased with increasing WFNS scores, modified Fisher scores and serum C-reactive protein concentrations. Serum IL-33 emerged as an independent predictor for 6-month mortality and poor outcome. Under receiver operating characteristic curve, the prognostic predictive ability of serum IL-33 was equivalent to those of WFNS scores and modified Fisher scores. Moreover, serum IL-33 significantly improved the prognostic predictive performance of WFNS scores and modified Fisher scores.

CONCLUSIONS

High serum IL-33 concentrations have close relation to the inflammation, severity and poor outcome in aSAH, indicating IL-33 might have the potential to be an inflammatory biomarker for assessing severity and reflecting prognosis of aSAH.

Dose-Dependent Inhibitory Effects of Cilostazol on Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Cilostazol is a selective inhibitor of phosphodiesterase type III that downregulates tenascin-C (TNC), a matricellular protein, which may cause delayed cerebral infarction after aneurysmal subarachnoid hemorrhage (SAH). The authors increased the dosage and evaluated the dose-dependent effects of cilostazol on delayed cerebral infarction and outcomes in SAH patients. This was a retrospective cohort study in a single center. One hundred fifty-six consecutive SAH patients including 67 patients of admission World Federation of Neurological Surgeons grades IV-V who underwent aneurysmal obliteration within 48 h post-SAH from 2007 to 2017 were analyzed. Cilostazol (0 to 300 mg/day) was administered from 1-day post-clipping or post-coiling to day 14 or later. Cilostazol treatment dose-dependently decreased delayed cerebral infarction and tended to improve outcomes, although cilostazol did not affect other outcome measures including angiographic vasospasm. On multivariate analyses, 300 mg/day (100 mg three times) cilostazol independently decreased delayed cerebral infarction and improved 3-month outcomes, but other regimens including 200 mg/day (100 mg twice) cilostazol were not independent prognostic factors. Propensity score-matched analyses showed that the 300 mg/day cilostazol cohort had lower plasma TNC levels and a lower incidence of delayed cerebral infarction associated with better outcomes compared with the non-cilostazol cohort. The 300 mg/day cilostazol may improve post-SAH outcomes by reducing plasma TNC levels and delayed cerebral infarction, but not vasospasm. Further studies are warranted to investigate if 300 mg/day cilostazol is more beneficial to post-SAH outcomes than a usual dose of 200 mg/day cilostazol that was demonstrated to be effective in randomized controlled trials.

Matricellular proteins as possible biomarkers for early brain injury after aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage remains devastating, and the most important determinant of poor outcome is early brain injury (EBI). In clinical settings, as a surrogate marker of EBI, loss of consciousness at ictus, poor initial clinical grades, and some radiographic findings are used, but these markers are somewhat subjective. Thus, it is imperative to find biomarkers of EBI that have beneficial prognostic and therapeutic implications. In our opinion, an ideal biomarker is a molecule that is implicated in the pathogenesis of both EBI and subsequently developing delayed cerebral ischemia (DCI), being a therapeutic target, and can be measured easily in the peripheral blood in an acute stage. A good candidate of such a biomarker is a matricellular protein, which is a secreted, inducible and multifunctional extracellular matrix protein. There are many kinds of matricellular proteins reported, but only tenascin-C, osteopontin, galectin-3 and periostin are reported relevant to EBI and DCI. Reliable biomarkers of EBI may stratify aneurysmal subarachnoid hemorrhage patients into categories of risk to develop DCI, and allow objective monitoring of the response to treatment for EBI and earlier diagnosis of DCI. This review emphasizes that further investigation of matricellular proteins as an avenue for biomarker discovery is warranted.