Association between gastrointestinal bleeding and 3-year mortality in patients with acute, first-ever ischemic stroke

Association and temporal sequence of pneumonia and gastrointestinal bleeding after acute ischemic stroke

BACKGROUND

Stroke-associated pneumonia (SAP) and gastrointestinal bleeding (GIB) are common medical complications after stroke. The previous study suggested a strong association between SAP and GIB after stroke. However, little is known about the time sequence of SAP and GIB. In the present study, we aimed to verify the association and clarify the temporal sequence of SAP and GIB after ischemic stroke.

METHODS

Patients with ischemic stroke from in-hospital Medical Complication after Acute Stroke study were analyzed. Data on occurrences of SAP and GIB during hospitalization and the intervals from stroke onset to diagnosis of SAP and GIB were collected. Multiple logistic regression was used to evaluate the association between SAP and GIB. Kruskal-Wallis test was used to compare the time intervals from stroke onset to diagnosis of SAP and GIB.

RESULTS

A total of 1129 patients with ischemic stroke were included. The median length of hospitalization was 14 days. Overall, 86 patients (7.6%; 95% CI, 6.1-9.2%) developed SAP and 47 patients (4.3%; 95% CI, 3.0-5.3%) developed GIB during hospitalization. After adjusting potential confounders, SAP was significantly associated with the development of GIB after ischemic stroke (OR = 5.13; 95% CI, 2.02-13.00; P < 0.001). The median time from stroke onset to diagnosis of SAP was shorter than that of GIB after ischemic stroke (4 days vs. 5 days; P = 0.039).

CONCLUSIONS

SAP was associated with GIB after ischemic stroke, and the onset time of SAP was earlier than that of GIB. It is imperative to take precautions to prevent GIB in stroke patients with SAP.

Risk Factors and Prognosis Analysis of Upper Gastrointestinal Bleeding in Patients With Acute Severe Cerebral Stroke

GOALS

We aim to explore the relationship between the use of proton pump inhibitors (PPIs) and upper gastrointestinal bleeding (UGIB). We develop a nomogram model to predict mortality in critically ill stroke patients.

STUDY

This is a retrospective study based on the MIMIC IV database. We extracted clinical information including demographic data, comorbidities, and laboratory indicators. Univariate and multivariable logistic regressions were used to assess and identify risk factors for the occurrence of UGIB and for the in-hospital mortality of critically ill stroke patients. The resulting model was used to construct a nomogram for predicting in-hospital mortality.

RESULTS

Five thousand seven hundred sixteen patients from the MIMIC-IV database were included in our analysis. UGIB occurred in 109 patients (1.9%), whereas the PPI use rate was as high as 60.6%. Chronic liver disease, sepsis, shock, anemia, and increased level of urea nitrogen were independent risk factors for the occurrence of UGIB in severe stroke patients. We identified age, heart failure, shock, coagulopathy, mechanical ventilation, continuous renal replacement therapy, antiplatelet drugs, anticoagulation, simplified acute physiology score-II, and Glasgow coma score as independent risk factors for in-hospital mortality in severe stroke patients. The C-index for the final nomograms was 0.852 (95% confidence interval: 0.840, 0.864).

CONCLUSIONS

We found that the overall rate of UGIB in severe stroke patients is low, whereas the rate of PPI usage is high. In our study, PPI was not identified as a risk factor for the occurrence of UGIB and UGIB was not associated with all-cause mortality. More clinical trials are needed to evaluate the benefits of using PPI in critically ill stroke patients.

Gastrointestinal Bleeding in Patients With Acute Ischemic Stroke: A Literature Review

Stroke is an infarction of the central nervous system (brain, spinal cord, or retina) that results from a disruption in cerebral blood flow either due to ischemia or hemorrhage. Complications of acute stroke are common and include pneumonia, urinary tract infection, myocardial infarction, deep vein thrombosis, and pulmonary embolism, among several others, all of which increase the risk of poor clinical outcomes. Gastrointestinal bleeding is a well-known complication that can occur during the acute phase of stroke. In this review, we have summarized the existing data regarding the incidence, pathophysiology, risk factors, morbidity, mortality, and management strategies for gastrointestinal bleeding in patients with acute ischemic stroke.

Neutrophil-to-lymphocyte ratio at admission is a risk factor for in-hospital gastrointestinal bleeding in acute ischemic stroke patients after dual antiplatelet therapy: A case control study

BACKGROUND

Gastrointestinal bleeding is a clinically important complication in acute ischemic stroke patients after dual antiplatelet therapy. The present study was to explore the association between neutrophil-to-lymphocyte ratio (NLR) and in-hospital gastrointestinal bleeding in acute ischemic stroke (AIS) patients who had received dual antiplatelet therapy.

METHODS

This restrospective study enrolled AIS patients who had received dual antiplatelet therapy in our hospital from January 2019 to December 2021. Patients were divided into a bleeding group and a non-bleeding group according to whether they had in-hospital gastrointestinal bleeding. Propensity score matching was used to match the confounding variables between the two groups. Multivariate logistic regression was performed to evaluate the association between NLR and in-hospital gastrointestinal bleeding. Receiver operating characteristic (ROC) curve was used to test the prediction ability of NLR.

RESULTS

A total of 1130 patients were enrolled in this study. Before matching, there were 51 patients in the bleeding group, 1079 patients in the non-bleeding group. After matching, 49 pairs of patients were successfully matched. Multivariate regression revealed that NLR was an independent predictor of in-hospital gastrointestinal bleeding in AIS patients who had received dual antiplatelet therapy. The area under curve (AUC) of NLR in predicting in-hospital gastrointestinal bleeding was 0.908, the sensitivity and specificity were 0.878 and 0.857 respectively.

CONCLUSIONS

NLR at admission is a useful predictor of in-hospital gastrointestinal bleeding in acute ischemic stroke patients after dual antiplatelet therapy. Still, more prospective studies with larger sample size are needed to validate the result.

Gastrointestinal Dysfunction in Stroke

Gastrointestinal (GI) complications are seen in over 50% of ischemic stroke survivors; the most common complications are dysphagia, constipation, and GI bleeding. The bidirectional relationship of the gut-brain axis and stroke has recently gained traction, wherein stroke contributes to gut dysbiosis (alterations in the normal host intestinal microbiome) and gut dysbiosis perpetuates poor functional neurologic outcomes in stroke. It is postulated that the propagation of proinflammatory cells and gut metabolites (including trimethylamine N-oxide and short-chain fatty acids) from the GI tract to the central nervous system play a central role in gut-brain axis dysfunction. In this review, we discuss the known GI complications in acute ischemic stroke, our current knowledge from experimental stroke models for gut-brain axis dysfunction in stroke, and emerging therapeutics that target the gut-brain axis.

Lizhong decoction ameliorates pulmonary infection secondary to severe traumatic brain injury in rats by regulating the intestinal physical barrier and immune response

ETHNOPHARMACOLOGICAL RELEVANCE

The pathogenesis of pulmonary infection secondary to severe traumatic brain injury (sTBI) is closely related to damage to the intestinal barrier. Lizhong decoction (LZD) is a prominent traditional Chinese medicine (TCM) that is widely used in clinical treatment to regulate gastrointestinal movement and enhance resistance. Nevertheless, the role and mechanism of LZD in lung infection secondary to sTBI have yet to be elucidated.

AIM OF THE STUDY

Here, we evaluate the therapeutic effect of LZD on pulmonary infection secondary to sTBI in rats and discuss potential regulatory mechanisms.

MATERIALS AND METHODS

The chemical constituents of LZD were analyzed by ultra-high performance liquid chromatography-Q Exactive-tandem mass spectrometry(UPLC-QE-MS/MS). The efficacy of LZD on rats with lung infection secondary to sTBI was examined by changes in brain morphology, coma time, brain water content, mNSS score, colony counts, 16S rRNA/RNaseP/MRP30 kDa(16S/RPP30), myeloperoxidase (MPO) content and pathology of lung tissue. The concentration of fluorescein isothiocyanate(FITC)-dextran in serum and the contents of secretory immunoglobulin A (SIgA) in colon tissue were detected by enzyme-linked immunosorbent assay (ELISA). Subsequently, Alcian Blue Periodic acid Schiff (AB-PAS) was used to detect colonic goblet cells. Immunofluorescence (IF) was used to detect the expression of tight junction proteins. The proportions of CD3⁺ cell, CD4⁺CD8⁺ T cells, CD45⁺ cell and CD103+ cells in the colon were analyzed by flow cytometry (FC). In addition, colon transcriptomics were analyzed by Illumina mRNA-Seq sequencing. Real-time quantitative polymerase chain reaction (qRT‒PCR) was used to verify the genes associated with LZD alleviation of intestinal barrier function.

RESULTS

Twenty-nine chemical constituents of LZD were revealed with UPLC-QE-MS/MS analysis. Administration of LZD significantly reduced colony counts, 16S/RPP30 and MPO content in lung infection secondary to sTBI rats. In addition, LZD also reduced the serum FITC-glucan content and the SIgA content of the colon. Additionally, LZD significantly increased the number of colonic goblet cells and the expression of tight junction proteins. Furthermore, LZD significantly decreased the proportion of CD3⁺ cell, CD4⁺CD8⁺ T cells,CD45+ and CD103+ cells in colon tissue. Transcriptomic analysis identified 22 upregulated genes and 56 downregulated genes in sTBI compared to the sham group. The levels of seven genes were recovered after LZD treatment. qRT‒PCR successfully validated two genes (Jchain and IL-6) at the mRNA level.

CONCLUSION

LZD can improves sTBI secondary lung infection by regulating the intestinal physical barrier and immune response. Thees results suggested that LZD may be a prospective treatment for pulmonary infection secondary to sTBI.

Association of Proton Pump Inhibitor Prophylaxis on Clinical Outcome in Acute Ischemic Stroke in China: A Multicenter Retrospective Cohort Study

BACKGROUND

Overtreatment with proton pump inhibitors (PPIs) in acute ischemic stroke (AIS) patients continues to grow. We aimed to investigate the frequency of PPI prophylaxis without an appropriate indication in AIS patients in China and clarify the association between PPI prophylaxis and long-term prognosis.

METHODS

Based on a multicenter stroke registry database, neurological outcomes, stroke events, recurrent ischemic strokes, and all-cause death were compared between patients with and without PPI prophylaxis.

RESULTS

A total of 4542 AIS were included, and 3335 (73.4%) received PPI prophylaxis. Patients with PPI prophylaxis were more likely to have a poor outcome at 1 year than those without PPI prophylaxis (33.3% vs. 25.8%, OR 1.321; 95% CI 1.102-1.584; p = 0.003). No significant differences were found in all-cause death, stroke event, or recurrent ischemic stroke at 1 year between the two groups. After propensity score matching, PPI prophylaxis was still independently associated with a higher rate of poor outcome (30.9% vs. 25.8%, OR 1.432; 95% CI 1.151-1.780; p = 0.001). Sensitivity analysis also showed that PPI prophylaxis increased the rate of a poor outcome in minor strokes or at different durations of PPI prophylaxis.

CONCLUSIONS

Approximately 3/4 of AIS patients were given PPI prophylaxis during hospitalization, which was associated with a poor long-term outcome.

Peripheral Organ Injury After Stroke

Stroke is a disease with high incidence, mortality and disability rates. It is also the main cause of adult disability in developed countries. Stroke is often caused by small emboli on the inner wall of the blood vessels supplying the brain, which can lead to arterial embolism, and can also be caused by cerebrovascular or thrombotic bleeding. With the exception of recombinant tissue plasminogen activator (rt-PA), which is a thrombolytic drug used to recanalize the occluded artery, most treatments have been demonstrated to be ineffective. Stroke can also induce peripheral organ damage. Most stroke patients have different degrees of injury to one or more organs, including the lung, heart, kidney, spleen, gastrointestinal tract and so on. In the acute phase of stroke, severe inflammation occurs in the brain, but there is strong immunosuppression in the peripheral organs, which greatly increases the risk of peripheral organ infection and aggravates organ damage. Nonneurological complications of stroke can affect treatment and prognosis, may cause serious short-term and long-term consequences and are associated with prolonged hospitalization and increased mortality. Many of these complications are preventable, and their adverse effects can be effectively mitigated by early detection and appropriate treatment with various medical measures. This article reviews the pathophysiological mechanism, clinical manifestations and treatment of peripheral organ injury after stroke.

Effect of Gastrointestinal Hemorrhage on Outcome After Endovascular Treatment in Acute Basilar Artery Occlusion

Background and Purpose

Gastrointestinal hemorrhage (GIH) is associated with a poorer prognosis and a higher mortality rate after acute ischemic stroke (AIS), but its association with outcomes after endovascular treatment (EVT) remains unclear. This study aimed to assess the incidence, risk factors, and relationships among clinical outcomes of GIH after EVT in patients with acute basilar artery occlusion (BAO).

Methods

Consecutive patients treated with EVT were identified from the EVT for Acute Basilar Artery Occlusion Study (BASILAR) registry. All enrolled patients were divided into GIH and non-GIH subgroups, and the independent predictors of GIH after EVT were explored. An ordinal logistic regression model was used to assess the association between GIH and primary outcome [distribution of modified Rankin scale (mRS)] at 90 days, while binary logistic regression models for other outcomes were also employed.

Results

Among 647 patients with acute BAO, 114 (17.6%) patients experienced GIH after EVT. Higher glucose levels at admission, longer procedure time, and general anesthesia were the independent predictors of GIH after EVT, while protective factors include the posterior circulation-Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) ≥ 5 and a history of hyperlipidemia. Compared with the non-GIH group, the GIH group was associated with a worse functional outcome [adjusted common odds ratio (OR), 2.12 (95% CI, 1.39–3.25)], lower rates of functional independence [adjusted OR,.47 (95% CI, 0.26–0.88)], a favorable outcome [adjusted OR, 0.41 (95% CI, 0.22–0.73)], and a higher risk of 90-day mortality [adjusted OR, 1.76 (95% CI, 1.08–2.85)].

Conclusion

This study concluded that GIH is not uncommon after EVT in patients with acute BAO and is associated with worse functional disability and higher mortality.

Brain to periphery in acute ischemic stroke: Mechanisms and clinical significance

The social and public health burdens of ischemic stroke have been increasing worldwide. In addition to focal brain damage, acute ischemic stroke (AIS) provokes systemic abnormalities across peripheral organs. AIS profoundly alters the autonomic nervous system, hypothalamic-pituitary-adrenal axis, and immune system, which further yield deleterious organ-specific consequences. Poststroke systemic pathological alterations in turn considerably contribute to the progression of ischemic brain injury, which accounts for the substantial impact of systemic complications on stroke outcomes. This review provides a comprehensive and updated pathophysiological model elucidating the systemic effects of AIS. To address their clinical significance and inform stroke management, we also outline the resulting systemic complications at particular stages of AIS and highlight the mechanisms. Future therapeutic strategies should attempt to integrate the treatment of primary brain lesions with interventions for secondary systemic complications, and should be tailored to patient individualized characteristics to optimize stroke outcomes.

Gastrointestinal bleeding during acute ischaemic stroke hospitalisation increases the risk of stroke recurrence

Objective

Gastrointestinal (GI) bleeding in patients who had a stroke is strongly associated with a higher risk of death and loss of independence. However, it is unknown whether GI bleeding increases risk for recurrence of stroke. In this study, we assess the potential relationship between GI bleeding and stroke recurrence in patients within 12 months of an acute ischaemic stroke (AIS), using the China National Stroke Registry (CNSR).

Methods

This study included 22 216 patients who had an ischaemic stroke included in the CNSR from 2007 to 2008. We analysed baseline patient characteristics, GI bleeding and outcomes of patients who had an AIS, specifically stroke recurrence at 3, 6 and 12 months. We used multivariable logistic regression to evaluate a possible association between GI bleeding and stroke recurrence.

Results

Of the 12 415 patients included in our study, 12.3%, 15.5% and 17.7% had a stroke recurrence at 3, 6 and 12 months, respectively. GI bleeding was an independent stroke recurrence risk factor in patients after ischaemic stroke at 3 months (adjusted OR 1.481, 95% CI 1.118 to 1.962), 6 months (adjusted OR 1.448, 95% CI 1.106 to 1.896) and 12 months (adjusted OR 1.350; 95% CI 1.034 to 1.763).

Conclusion

GI bleeding was associated with the increased risk of stroke recurrence after an AIS.

Neuroimmune crosstalk in central nervous system injury-induced infection and pharmacological intervention

Infection (such as pneumonia and urinary tract infection) is one of the leading causes of death in patients with acute central nervous system (CNS) injury, which also greatly affects the patients' prognosis and quality of life. Antibiotics are commonly used for the treatment of various infections, however, available evidence demonstrate that prophylactic antibiotic treatments for CNS injury-induced infection have been unsuccessful. Effective approaches for prevention of CNS injury induced-infection remain scarce, therefore, better understanding the molecular and cellular mechanisms of infection post-CNS injury may aid in the development of efficacious therapeutic options. CNS injury-induced infection is confirmed affected by the sympathetic/parasympathetic nervous system, hypothalamic-pituitary-adrenal axis, and even brain-gut axis. In this review, we summarized the mechanisms of CNS injury- induced infection, crosstalk between the CNS and the immune system and current pharmacological intervention to provide ideas for the development of new anti- infective therapeutic strategies.

Factors affecting the occurrence of gastrointestinal bleeding in acute ischemic stroke patients

Gastrointestinal bleeding (GIB) is a common complication that occurs after stroke, and GIB may negatively affect patient prognosis. In this study, we aimed to examine:(1) the risk factors of GIB in acute cerebral infarction patients;(2) association between GIB and 1-year mortality in patients with acute cerebral infarction.Patients with acute cerebral infarction were divided into 2 groups based on the occurrence of GIB during acute stroke stage. Patient characteristics, clinical presentation, stroke risk factors, comorbidities, laboratory data, medication, and outcomes were investigated to analyze the associations between the variables and the probability of having GIB. In addition, patients in the study were matched individually by age, gender. A 1:1 matched case-control method and conditional logistic regression models for single and multiple factors were used to assess the risk factors of GIB in acute cerebral infarction patients.Clinical data of patients with acute cerebral infarction were reviewed and analyzed during the years 2015 and 2016. Finally, 1662 patients with acute cerebral infarction were included in this study, of whom 139 (8.5%) patients had GIB at admission. Multivariate logistic regression analysis revealed that the independent risk factors for GIB in patients with acute cerebral infarction were advanced age (OR = 1.030, P = .009), low Glasgow Coma Scale (GSC) score (OR = 0.850, P = .014), infection (OR = 4.693, P < .001), high NIHSS score (OR = 1.114, P = .001), and posterior circulation infarction (OR = 4.981, P = .010). The case-control study ultimately included 136 case-control pairs. Stepwise conditional regression analyses revealed that the independent risk factors for GIB in patients with acute cerebral infarction were low Glasgow Coma Scale (GSC) score (RR = 0.645, P = .011), infection (RR = 15.326, P = .001), and posterior circulation infarction (RR = 6.129, P = .045). The group with GIB had a higher rate of mortality and disability level (mRS grade ≥ 4) than the group without GIB (P < .001) within 1 year after stroke. In addition, independent risk factors of death within 1 year after stroke in patients were GIB (OR = 6.096, P < .001), infection (OR = 4.493, P < .001), mRS grade ≥ 4 (OR = 4.129, P < .001), and coronary heart disease (OR = 3.718, P = .001).GIB is a common complication after ischemic stroke. These identified factors may help clinicians identify risks of GIB before it develops. GIB is associated with increased risk of 1-year mortality and poor functional outcome in acute cerebral infarction patients.