Glycosylated Hemoglobin and Functional Outcome after Acute Ischemic Stroke

Glycosylation: A new signaling paradigm for the neurovascular diseases

A wide range of life-threatening conditions with complicated pathogenesis involves neurovascular disorders encompassing Neurovascular unit (NVU) damage. The pathophysiology of NVU is characterized by several features including tissue hypoxia, stimulation of inflammatory and angiogenic processes, and the initiation of intricate molecular interactions, collectively leading to an elevation in blood-brain barrier permeability, atherosclerosis and ultimately, neurovascular diseases. The presence of compelling data about the significant involvement of the glycosylation in the development of diseases has sparked a discussion on whether the abnormal glycosylation may serve as a causal factor for neurovascular disorders, rather than being just recruited as a secondary player in regulating the critical events during the development processes like embryo growth and angiogenesis. An essential tool for both developing new anti-ischemic therapies and understanding the processes of ischemic brain damage is undertaking pre-clinical studies of neurovascular disorders. Together with the post-translational modification of proteins, the modulation of glycosylation and its enzymes implicates itself in several abnormal activities which are known to accelerate neuronal vasculopathy. Despite the failure of the majority of glycosylation-based preclinical and clinical studies over the past years, there is a significant probability to provide neuroprotection utilizing modern and advanced approaches to target abnormal glycosylation activity at embryonic stages as well. This article focuses on a variety of experimental evidence to postulate the interconnection between glycosylation and vascular disorders along with possible treatment options.

Impact of glycosylated hemoglobin on early neurological deterioration in acute mild ischemic stroke patients treated with intravenous thrombolysis

Objective

In patients with acute mild ischemic stroke treated with intravenous thrombolysis, the relationship between chronic hyperglycemic status and their early neurological deterioration (END) and clinical outcomes is unclear. We attempted to analyze the relationship between glycated hemoglobin (HbA1c) levels and END and 90-day functional outcomes.

Participants and methods

The research comprised 267 patients with acute mild ischemic stroke. The incidence of END and functional outcomes at 90 days were evaluated between subgroups. END was defined in this study as a rise of at least 1 point in the National Institutes of Health Stroke Scale (NIHSS) score within 72 h of admission, with an excellent outcome of a modified Rankin Scale (mRS) score of 0-1 at 90 days following stroke beginning. The association between HbA1c and END, and clinical outcomes in patients with mild stroke, was assessed by logistic regression after adjusting for confounding factors. In addition, we used receiver operating characteristic (ROC) curves to predict the predictive value of HbA1c for the incidence of END.

Results

There were 38 patients who suffered END and 105 patients who had disabled functional outcomes at 90 days. In multivariate analysis, elevated HbA1c levels were associated with END (adjusted OR = 1.476; 95% CI: 1.129-1.928; p = 0.004). With HbA1c greater than 7.75%, the ROC curve predicted a higher risk of END. However, they were not associated with patients' functional outcomes at 90 days.

Conclusion

HbA1c levels were an independent predictor of END in patients with mild stroke, while there was no effect on functional outcomes at 90 days. The impact of HbA1c on functional prognosis may be a contributing factor rather than a direct factor.

The acute-to-chronic glycemic ratio correlates with the severity of illness at admission in patients with diabetes experiencing acute ischemic stroke

Acute hyperglycemia is a powerful indicator of the severity of acute ischemic stroke (AIS); however, the relationship between these two factors is not very clear in patients with diabetes. We aimed to retrospectively evaluate data from 335 consecutive patients who experienced AIS from November 2015 to November 2016 to investigate whether a comprehensive assessment of blood glucose levels is a more valuable indicator of the severity of AIS or the presence of acute hyperglycemia in patients with diabetes. We collected demographic data, clinical manifestation information, clinical scores, and laboratory data [including fasting blood glucose and glycated hemoglobin (HbA1c) levels]. We estimated prehospital mean blood glucose concentrations using the following formula [1.59 * HbA1c (%) – 2.59] to calculate the “Acute-to-Chronic Glycemic Ratio” (AC ratio). The AC ratio differed significantly among patients grouped according to the National Institutes of Health Stroke Scale/Score (NIHSS) at admission (admission NIHSS) (p = 0.006). Univariate regression analysis revealed a correlation between the AC ratio and admission NIHSS [standardized β-coefficient (Std. B) = 0.164, p = 0.004]. The adjusted linear regression analysis revealed a correlation between both HbA1c (Std. B = 0.368, p = 0.038) and the AC ratio (Std. B = 0.262, p = 0.022) and admission NIHSS. The AC ratio (Std. B = 0.161, p = 0.012) was related to admission NIHSS in the stepwise variable selection. For an admission NIHHS > 4, the AC ratio (Std. B = 0.186, p = 0.047) was related to admission NIHSS in the stepwise variable selection. The AC ratio (Std. B = 1.163, p = 0.006 and Std. B = 0.565, p = 0.021, respectively) were related to admission NIHSS in both large-artery atherosclerosis (LAA) and small-vessel occlusion (SVO) subgroups. Thus, the AC ratio is related to admission NIHSS in patients with diabetes who experienced AIS and may be a better indicator of severity than acute blood glucose levels.

Measuring of Advanced Glycation End Products in Acute Stroke Care: Skin Autofluorescence as a Predictor of Ischemic Stroke Outcome in Patients with Diabetes Mellitus

Background: Patients with diabetes mellitus (DM) are known to show poor recovery after stroke. This specific burden might be due to acute and chronic hyperglycemic effects. Meanwhile, the underlying mechanisms are a cause of discussion, and the best measure to predict the outcome is unclear. Skin autofluorescence (SAF) reflects the in-patient load of so-called advanced glycation end products (AGEs) beyond HbA1c and represents a valid and quickly accessible marker of chronic hyperglycemia. We investigated the predictive potential of SAF in comparison to HbA1c and acute hyperglycemia on the functional outcome at 90 days after ischemic stroke in a cohort of patients with DM. Methods: We prospectively included 113 patients with DM type 2 hospitalized for acute ischemic stroke. SAF was measured on each patient’s forearm by a mobile AGE-Reader mu© in arbitrary units. HbA1c and the area under the curve (AUC) of the blood sugar profile after admission were assessed. Functional outcome was assessed via phone interview after 90 days. A poor outcome was defined as a deterioration to a modified Rankin Scale score ≥ 3. A good outcome was defined as a modified Rankin Scale score < 3 or as no deterioration from premorbid level. Results: Patients with a poor outcome presented with higher values of SAF (mean 3.38 (SD 0.55)) than patients with a good outcome (mean 3.13 (SD 0.61), p = 0.023), but did not differ in HbA1c and acute glycemia. In logistic regression analysis, age (p = 0.021, OR 1.24 [1.12−1.37]) and SAF (p = 0.021, OR 2.74 [1.16−6.46]) significantly predicted a poor outcome, whereas HbA1c and acute glycemia did not. Patients with a poor 90-day outcome and higher SAF experienced more infections (4.2% vs. 33.3% (p < 0.01)) and other various in-hospital complications (21.0% vs. 66.7% (p < 0.01)) than patients with a good outcome and lower SAF levels. Conclusions: SAF offers an insight into glycemic memory and appears to be a significant predictor of poor stroke outcomes in patients with DM exceeding HbA1c and acute glycemia. Measuring SAF could be useful to identify specifically vulnerable patients at high risk of complications and poor outcomes.

Predictive value of hemoglobin level on early neurological outcomes in acute ischemic stroke

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.

Relationships Among Gut Microbiota, Ischemic Stroke and Its Risk Factors: Based on Research Evidence

Stroke is a highly lethal disease and disabling illness while ischemic stroke accounts for the majority of stroke. It has been found that inflammation plays a key role in the initiation and progression of stroke, and atherosclerotic plaque rupture is considered to be the leading cause of ischemic stroke. Furthermore, chronic inflammatory diseases, such as obesity, type 2 diabetes mellitus (T2DM) and hypertension, are also considered as the high-risk factors for stroke. Recently, the topic on how gut microbiota affects human health has aroused great concern. The initiation and progression of ischemic stroke has been found to have close relation with gut microbiota dysbiosis. Hence, this manuscript briefly summarizes the roles of gut microbiota in ischemic stroke and its related risk factors, and the practicability of preventing and alleviating ischemic stroke by reconstructing gut microbiota.

Stress hyperglycemia is associated with in-hospital mortality in patients with diabetes and acute ischemic stroke

Background and Objective

Stress hyperglycemia may occur in diabetic patients with acute severe cerebrovascular disease, but the results regarding its association with stroke outcomes are conflicting. This study aimed to examine the association between stress‐induced hyperglycemia and the occurrence of in‐hospital death in patients with diabetes and acute ischemic stroke.

Research Design and Methods

All data were from the Chinese Stroke Center Alliance (CSCA) database and were collected between 2016 and 2018 from >300 centers across China. Patients’ demographics, clinical presentation, and laboratory data were extracted from the database. The primary endpoint was in‐hospital death. The ratio of fasting blood glucose (FBG) to HbA1c was calculated, that is, the stress‐induced hyperglycemia ratio (SHR), to determine stress hyperglycemia following acute ischemic stroke.

Results

A total of 168,381 patients were included. The mean age was 66.2 ± 10.7, and 77,688 (43.0%) patients were female. The patients were divided into two groups: survivors (n = 167,499) and non‐survivors (n = 882), as well as into four groups according to their SHR quartiles (n = 42,090–42,099/quartile). There were 109 (0.26%), 142 (0.34%), 196 (0.47%), and 435 (1.03%) patients who died in the Q1, Q2, Q3, and Q4 quartiles, respectively. Compared with Q1 patients, the death risk was higher in Q4 patients (odds ratio (OR) = 4.02) (adjusted OR = 1.80, 95% confidence interval [CI] = 1.10–2.92, p = 0.018 after adjustment for traditional cardiovascular risk factors). The ROC analyses showed that SHR (AUC = 0.667, 95% CI: 0.647–0.686) had a better predictive value for mortality than that of fasting blood glucose (AUC = 0.633, 95% CI: 0.613–0.652) and HbA1c (AUC = 0.523, 95% CI: 0.504–0.543).

Conclusions

The SHR may serve as an accessory parameter for the prognosis of patients with diabetes after acute ischemic stroke. Hyperglycemia in stroke patients with diabetes mellitus is associated with a higher risk of in‐hospital death.

High glycemic albumin representing prestroke glycemic variability is associated with hemorrhagic transformation in patients receiving intravenous thrombolysis

We evaluated the impact of prestroke glycemic variability estimated by glycated albumin (GA) on symptomatic hemorrhagic transformation (SHT) in patients with intravenous thrombolysis (IVT). Using a multicenter database, we consecutively enrolled acute ischemic stroke patients receiving IVT. A total of 378 patients were included in this study. Higher GA was defined as GA ≥ 16.0%. The primary outcome measure was SHT. Multivariate regression analysis and a receiver operating characteristic curve were used to assess risks and predictive ability for SHT. Among the 378 patients who were enrolled in this study, 27 patients (7.1%) had SHT as defined by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SHT_SITS). The rate of SHT_SITS was higher in the higher GA group than in the lower GA group (18.0% vs. 1.6%, p < 0.001). A higher GA level (GA ≥ 16.0%) significantly increased the risk of SHT_SITS (adjusted odds ratio [OR], [95% confidence interval, CI], 12.57 [3.08–41.54]) in the logistic regression analysis. The predictive ability of the GA level for SHT_SITS was good (AUC [95% CI]: 0.83 [0.77–0.90], p < 0.001), and the cutoff value of GA in SHT was 16.3%. GA was a reliable predictor of SHT after IVT in acute ischemic stroke in this study.

Effect of Diabetes on Post-stroke Recovery: A Systematic Narrative Review

Background: Patients with stroke often have comorbid diabetes. Considering its detrimental effects on brain function, diabetes may increase the risk of poor recovery.

Methods: The aim of this review was to investigate the effect of diabetes on post-stroke recovery by a systematic review. Several specific aspects of post-stroke recovery, including activities of daily living (ADL), motor, cognitive, and quality of life (QOL) recovery, were examined. We searched the PubMed, SCOPUS, Embase, and Cochrane Library databases for relevant studies on the effect of diabetes on post-stroke recovery, published until May 26, 2021. A total of 52,051 potentially relevant articles were identified. After reading the titles and abstracts and assessing their eligibility based on full-text articles, 34 publications were included in this review.

Results: Of 29 studies that assessed ADL recovery after stroke, 22 studies suggested that diabetes had a negative effect on recovery of ADL after stroke. Regarding motor recovery, only one out of four studies showed that diabetes had some effect on motor recovery after stroke. Of the two studies on cognitive recovery, one reported that diabetes was an independent predictor of poor cognitive recovery after stroke. Three studies on QOL reported that a poor QOL after stroke was associated with the presence of diabetes.

Conclusions: The current review suggests that the post-stroke recovery of ADL seems to be poorer in patients with diabetes than patients without diabetes. Further, there are insufficient data to conclude the effect of diabetes on motor and cognitive recovery, but it may have some influence on the quality of life after stroke.

Systematic Review Registration: doi: 10.37766/inplasy2021.11.0032, identifier: INPLASY2021110032.

Early neutrophil-to-lymphocyte ratio is a prognostic marker in acute minor stroke or transient ischemic attack

Intravenous injection of alteplase is recommended for patients with minor disabling and not non-disabling ischemic stroke symptoms within 4.5 h of ischemic stroke symptom onset. However, it is hard for clinicians to distinguish which type of minor ischemic stroke is disabled at an early stage. In this study, we aimed to demonstrate early neutrophil-to-lymphocyte ratio is a prognostic marker in acute minor stroke or transient ischemic attack. 196 patients diagnosed with acute minor stroke or transient ischemic attack within 24 h of symptom onset were enrolled. Patients were divided into three groups according to the neutrophil-to-lymphocyte ratio value (< 2, 2-3, > 3). Clinical, neuroradiological, laboratory and follow-up data were collected from electronic database. Functional outcome was assessed by modified Rankin Scale. Neutrophil-to-lymphocyte ratio associated with functional outcome of 90 days was evaluated by logistic regression analysis, and we used receiver operating characteristic curve analysis to detect the overall predictive accuracy of this marker. Early neutrophil-to-lymphocyte ratio was associated with an increased risk of short-term functional outcome (OR 4.502, 95% CI 1.533-13.046, P = 0.006). The optimal cutoff value of neutrophil-to-lymphocyte ratio for prediction of short-term unfavorable outcome was 2.94 with a sensitivity of 69.6% and a specificity of 77.1% (area under the curve: 0.767, 95% CI 0.691-0.843). Early neutrophil-to-lymphocyte ratio is associated with short-term unfavorable functional outcome in patients with acute minor stroke or transient ischemic attack. Early neutrophil-to-lymphocyte ratio is beneficial for clinicians to distinguish minor disabling ischemic stroke at an early stage.

Association Between Raised HbA1c Levels and Hemorrhagic Transformation in Patients With Ischemic Stroke

Background Glycated hemoglobin (HbA1c) is a commonly used indicator of glycemic control in diabetes mellitus. Uncontrolled diabetes can lead to cardiovascular complications. Ischemic strokes are often complicated by hemorrhagic transformation, which is the conversion of an infarcted area into an area of hemorrhage. The purpose of this study is to determine the association of raised HbA1c levels with the occurrence of hemorrhagic transformation in ischemic stroke. Methods This is a prospective, single-center cohort study of patients admitted to the Neurology and Medicine wards between June 1 and November 30, 2019. Inclusion criteria included adult patients who were admitted with acute ischemic stroke and had been tested for HbA1c on presentation. There were 110 ischemic stroke patients enrolled in our database. An HbA1c level >53 mmol/mol was considered raised. A comparison was done between the group with raised HbA1c levels and the group with target levels of HbA1c for the occurrence of hemorrhagic transformation. Brain imaging was used to diagnose hemorrhagic transformation. Results Out of 110 study participants with ischemic stroke, 70 (63.6%) patients had a history of prior known diabetes. The mean HbA1c levels were 7.44 ± 1.79%. A total of 77% of diabetic patients had raised HbA1c levels (>7%). Hemorrhagic transformation was seen in 21 (19.1%) patients, of whom only 38% (n=8) had raised HbA1c levels. The association between raised HbA1c and hemorrhagic transformation was not found to be statistically significant (p = 0.225). Conclusion In this study of patients with ischemic stroke, raised HbA1c levels were not found to be associated with hemorrhagic transformation. There is a need for larger scale studies to find out the cause and mechanism of hemorrhagic transformation in ischemic stroke.

Biomarkers Predictive of Long-Term Outcome After Ischemic Stroke: A Meta-Analysis

BACKGROUND AND PURPOSE

The goal of this study was to systematically review the utility of serum biomarkers in the setting of ischemic stroke (IS) to predict long-term outcome.

METHODS

A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986-2018. All studies assessing long-term functional outcome (defined as 30 days or greater) following IS with respect to serum biomarkers were included. Data were extracted and pooled using a meta-analysis of odds ratios.

RESULTS

Of the total 2928 articles in the original literature search, 183 studies were ultimately selected. A total of 127 serum biomarkers were included. Biomarkers were grouped into several categories: inflammatory (32), peptide/enzymatic (30), oxidative/metabolic (28), hormone/steroid based (23), and hematologic/vascular (14). The most commonly studied biomarkers in each category were found to be CRP, S100β, albumin, copeptin, and D-dimer. With the exception of S100β, all were found to be statistically associated with >30-day outcome after ischemic stroke.

CONCLUSIONS

Serum-based biomarkers have the potential to predict functional outcome in IS patients. This meta-analysis has identified CRP, albumin, copeptin, and D-dimer to be significantly associated with long-term outcome after IS. These biomarkers have the potential to serve as a platform for prognosticating stroke outcomes after 30 days. These serum biomarkers, some of which are routinely ordered, can be combined with imaging biomarkers and used in artificial intelligence algorithms to provide refined predictive outcomes after injury. Ultimately these tools will assist physicians in providing guidance to families with regards to long-term independence of patients.

Red cell distribution width is associated with all-cause mortality in patients with acute stroke: a retrospective analysis of a large clinical database

Objectives

This study aimed to evaluate the association between the red blood cell distribution width (RDW) and mortality in patients with stroke.

Methods

We conducted a retrospective cohort study on patients with stroke in the Medical Information Mart for Intensive Care Database III. Cox proportional hazards regression models were used to estimate hazard ratios of 30-day, 90-day, and 1-year mortality in relation to the RDW level.

Results

A total of 4134 patients were enrolled, including 2646 patients with ischemic stroke and 1668 with hemorrhagic stroke. After adjustment for potential confounders, the hazard ratio (95% confidence interval) of 30-day mortality for the second (RDW: 13.4%–14.3%) and third (>14.3%) tertiles was 1.15 (0.96, 1.37) and 1.40 (1.17, 1.68), respectively, compared with the reference group (<13.4%). A two-piecewise linear regression model was established and the inflection point of RDW was 16.7%. When RDW was >16.7%, an increase in RDW did not increase stroke mortality.

Conclusions

The RDW is a prognostic factor of patients with stroke. This finding needs to be confirmed in future prospective studies.

Significantly Reduced Alanine Aminotransferase Level Increases All-Cause Mortality Rate in the Elderly after Ischemic Stroke

(1) Background: A significantly reduced alanine aminotransferase (ALT) level is being recognized as a risk factor of increasing mortality in the elderly in relation to frailty. In the elderly, both frailty and ischemic stroke are not only common, but are also associated with mortality. The aim of this research was to investigate whether a significantly reduced ALT level increases the all-cause mortality rate in the elderly with ischemic stroke. (2) Methods: Between February 2014 and April 2019, a retrospective study of 901 patients with ischemic stroke admitted to a university-affiliated hospital was conducted. Cox proportional hazard regression was used to determine whether a significantly reduced ALT level is an independent risk factor for mortality in elderly patients after an ischemic stroke. (3) Results: This study enrolled 323 older adults (age ≥ 65 years) who were first diagnosed with ischemic stroke. The mean age of the participants was 76.5 ± 6.6 years, the mean survival time was 37.1 ± 20.4 months, and the number of deaths was 96 (29.7%). Our results showed that reduced ALT level (less than 10 U/L) increased the risk of all-cause mortality in the elderly after ischemic stroke (adjusted HR: 3.24, 95% CI: 1.95–5.41; p < 0.001). (4) Conclusions: A significantly reduced ALT level at the time of diagnosis (less than 10 U/L) is an independent risk factor that increases the mortality rate in the elderly after ischemic stroke.

Glycated Hemoglobin as a Marker for Predicting Outcomes of Patients With Stroke (Ischemic and Hemorrhagic): A Systematic Review and Meta-Analysis

Background: Glycated hemoglobin (HbA1c) has emerged as a useful biochemical marker reflecting the average glycemic control over the last 3 months, and the values are not affected by short-term transient changes in blood glucose levels. However, its prognostic value in the acute neurological conditions such as stroke is still not well-established. The present meta-analysis was conducted to assess the relationship of HbA1c with outcomes such as mortality, early neurological complications, and functional dependence in stroke patients.

Methods: A systematic search was conducted for the PubMed, Scopus, and Google Scholar databases. Studies, either retrospective or prospective in design that examined the relationship between HbA1c with outcomes of interest and presented the strength of association in the form of adjusted odds ratio/hazard ratios were included in the review. Statistical analysis was done using STATA version 13.0.

Results: A total of 22 studies (15 studies on acute ischemic stroke and seven studies on hemorrhagic stroke) were included in the meta-analysis. For patients with acute ischemic stroke, each unit increase in HbA1c was found to be associated with an increased risk of mortality within 1 year, increased risk of poor functional outcome at 3 months, and an increased risk of symptomatic intracranial hemorrhage (sICH) within 24 h of admission. In those with HbA1c ≥ 6.5%, there was an increased risk of mortality within 1 year of admission, increased risk of poor functional outcomes at 3 and 12 months as well as an increased risk of symptomatic intracranial hemorrhage (sICH) within 24 h of admission. In patients with hemorrhagic stroke, each unit increase in HbA1c was found to be associated with increased risk of poor functional outcome within the first 3 months from the time of admission for stroke. In those with HbA1c ≥ 6.5%, there was an increased risk of poor functional outcome at 12 months.

Conclusions: The findings indicate that glycated hemoglobin (HbA1c) could serve as a useful marker to predict the outcomes in patients with stroke and aid in the implementation of adequate preventive management strategies at the earliest.

Chronic hyperglycemia before acute ischemic stroke impairs the bilateral cerebrovascular response to exercise during the subacute recovery period

BACKGROUND AND PURPOSE

Chronic hyperglycemia contributes to cerebrovascular dysfunction by damaging blood vessels. Poor glucose control has been tied to impairments in cerebral blood flow, which may be particularly detrimental for people recovering from major cerebrovascular events such as acute ischemic stroke. In this secondary analysis, we explore for the first time the connection between chronic hyperglycemia before acute stroke and the cerebrovascular response (CVR) to exercise 3 and 6 month into the subacute recovery period.

METHODS

We recorded middle cerebral artery velocity (MCAv) using transcranial Doppler ultrasound bilaterally at rest and during moderate-intensity exercise in stroke patients at 3 (n = 19) and 6 (n = 12) months post-stroke. We calculated CVR as the difference between MCAv during steady-state exercise and resting MCAv. We obtained hemoglobin A1c levels (HbA1c; a measure of blood glucose over the prior 3 months) from the electronic medical record (EMR) and divided participants by HbA1c greater or less than 7%.

RESULTS

Participants with high HbA1c (>7%) at the time of acute stroke had significantly lower CVR to exercise for both the stroke-affected (p = .009) and non-affected (p = .007) hemispheres at 3 months post-stroke. These differences remained significant at 6 months post-stroke (stroke-affected, p = .008; non-affected, p = .016).

CONCLUSIONS

Patients with chronic hyperglycemia before acute ischemic stroke demonstrated impaired cerebrovascular function during exercise months into the subacute recovery period. These findings highlight the importance of maintaining tight glucose control to reduce morbidity and improve recovery post-stroke and could have implications for understanding cerebrovascular pathophysiology.

Correlation between self-perceived burden and self-management behavior in elderly stroke survivors: A longitudinal observational study

The aim of this study was to assess the levels of self-perceived burden (SPB) and self-management behavior in elderly stroke survivors during the first 3 months after acute stroke, and to explore the correlation between them.A total of 203 consecutive hospitalized elderly patients diagnosed with stroke were recruited. Self-perceived Burden Scale and Stroke Self-management Scale in 1 month (T1) and 3 months (T2) post-stroke were assessed and compared.The score of SPB in elderly stroke survivors was 28.96 ± 5.50 and 27.25 ± 6.17 at T1 and T2, respectively. Stroke self-management scale scored 165.93 ± 9.82 at T1 and 167.29 ± 10.60 at T2. In the first 3 months post-stroke, the physical burden was dominant (T1 14.73 ± 3.07, T2 14.40 ± 3.13), and the behavior of stroke symptoms and signs monitoring (T1 27.58 ± 6.56, T2 28.64 ± 6.43) and rehabilitation exercise management (T1 21.40 ± 3.28, T2 20.74 ± 3.15) was the worst. SPB was negatively correlated with self-management behavior (T1 r = -.202, T2 r = -.511).Elderly stroke survivors experienced a medium level of SPB and self-management behavior in the first 3 months post-stroke. There is a positive relationship between reduced SPB and improved self-management behavior. Addressing the characteristics and correlations as well as development of targeted interventions for SPB decreasing is beneficial to improving self-management behavior for elderly survivors.

Diabetes in ischaemic stroke in a regional Australian hospital - uncharted territory

BACKGROUND

Stroke and diabetes (DM) are significant interrelated healthcare issues but there is a dearth of data on the prevalence of DM among Australia's regional stroke population.

AIMS

We aimed to determine the prevalence of DM in stroke patients at a large regional centre, including sub-analyses on stroke subtypes, glycaemic control and renal function in ischaemic stroke (IS).

METHODS

We conducted a retrospective analysis of all patients (n = 323) with IS or transient ischaemic attack (TIA) admitted to Ballarat Base Hospital from January 2015 to December 2016. Demographic data, cardiovascular risk factors, aetiology/territory of IS, pre-morbid DM status, indicators of glycaemic control and renal impairment were recorded.

RESULTS

DM was present in 28.5% of IS and TIA patients including 4% being newly diagnosed. Among diabetic IS patients, 45.3% had poor glycaemic control (HbA1c ≥7.0%) while 16% had moderate to severe renal impairment (eGFR of <30). The majority of IS were partial anterior circulation stroke (53.4%) and cardioembolism was the commonest mechanism (43.5%). We found no significant association between DM and a specific stroke location or mechanism.

CONCLUSION

Almost a third of IS/TIA patients had DM with a significant proportion showing poor glycaemic control. The DM prevalence in our cohort was comparable to reported rates from other developed countries. While we found no association between DM and a particular stroke type or mechanism, it is likely a reflection of our cohort size. Our study demonstrated that DM, as a significant risk factor in IS, warrants early detection and better management strategies. This article is protected by copyright. All rights reserved.

Predictors of urinary tract infection in acute stroke patients: A cohort study

Patients with stroke have a high risk of infection which may be predicted by age, procalcitonin, interleukin-6, C-reactive protein, National Institute of Health stroke scale (NHSS) score, diabetes, etc. These prediction methods can reduce unfavourable outcome by preventing the occurrence of infection.We aim to identify early predictors for urinary tract infection in patients after stroke.In 186 collected acute stroke patients, we divided them into urinary tract infection group, other infection type groups, and non-infected group. Data were recorded at admission. Independent risk factors and infection prediction model were determined using Logistic regression analyses. Likelihood ratio test was used to detect the prediction effect of the model. Receiver operating characteristic curve and the corresponding area under the curve were used to measure the predictive accuracy of indicators for urinary tract infection.Of the 186 subjects, there were 35 cases of urinary tract infection. Elevated interleukin-6, higher NIHSS, and decreased hemoglobin may be used to predict urinary tract infection. And the predictive model for urinary tract infection (including sex, NIHSS, interleukin-6, and hemoglobin) have the best predictive effect.This study is the first to discover that decreased hemoglobin at admission may predict urinary tract infection. The prediction model shows the best accuracy.

A parsimonious score with a free web tool for predicting disability after an ischemic stroke: the Parsifal Score

BACKGROUND

Most of the models to predict prognosis after an ischemic stroke include complex mathematical equations or too many variables, making them difficult to use in the daily clinic. We want to predict disability 3 months after an ischemic stroke in an independent patient not receiving recanalization treatment within the first 24 h, using a minimum set of variables and an easy tool to facilitate its implementation. As a secondary aim, we calculated the capacity of the score to predict an excellent/devastating outcome and mortality.

METHODS

Eight hundred and forty-four patients were evaluated. A multivariable ordinal logistic regression was used to obtain the score. The Modified Rankin Scale (mRS) was used to estimate disability at the third month. The results were replicated in another independent cohort (378 patients). The "polr" function of R was used to perform the regression, stratifying the sample into seven groups with different cutoffs (from mRS 0 to 6).

RESULTS

The Parsifal score was generated with: age, previous mRS, initial NIHSS, glycemia on admission, and dyslipidemia. This score predicts disability with an accuracy of 80-76% (discovery-replication cohorts). It has an AUC of 0.86 in the discovery and replication cohort. The specificity was 90-80% (discovery-replication cohorts); while, the sensitivity was 64-74% (discovery-replication cohorts). The prediction of an excellent or devastating outcome, as well as mortality, obtained good discrimination with AUC > 0.80.

CONCLUSIONS

The Parsifal Score is a model that predicts disability at the third month, with only five variables, with good discrimination and calibration, and being replicated in an independent cohort.

Predicting Functional Outcome Based on Linked Data After Acute Ischemic Stroke: S-SMART Score

Prediction of outcome after stroke may help clinicians provide effective management and plan long-term care. We aimed to develop and validate a score for predicting good functional outcome available for hospitals after ischemic stroke using linked data. A total of 22,005 patients with acute ischemic stroke from the Clinical Research Center for Stroke Registry between July 2007 and December 2014 were included in the derivation group. We assessed functional outcomes using a modified Rankin scale (mRS) score at 3 months after ischemic stroke. We identified predictors related to good 3-month outcome (mRS score ≤ 2) and developed a score. External validations (geographic and temporal validations) of the developed model were performed. The prediction model performance was assessed using the area under the receiver operating characteristic curve (AUC) and the calibration test. Stroke severity, sex, stroke mechanism, age, pre-stroke mRS, and thrombolysis/thrombectomy treatment were identified as predictors for 3-month good functional outcomes in the S-SMART score (total 34 points). Patients with higher S-SMART scores had an increased likelihood of a good outcome. The AUC of the prediction score was 0.805 (0.798-0.811) in the derivation group and 0.812 (0.795-0.830) in the geographic validation group for good functional outcome. The AUC of the model was 0.812 (0.771-0.854) for the temporal validation group. Moreover, they had good calibration. The S-SMART score is a valid and useful tool to predict good functional outcome following ischemic stroke. This prediction model may assist in the estimation of outcomes to determine care plans after stroke.

Machine-learning prediction of self-care activity by grip strengths of both hands in poststroke hemiplegia

To investigate the relationships between grip strengths and self-care activities in stroke patients using a non-linear support vector machine (SVM).Overall, 177 inpatients with poststroke hemiparesis were enrolled. Their grip strengths were measured using the Jamar dynamometer on the first day of rehabilitation training. Self-care activities were assessed by therapists using Functional Independence Measure (FIM), including items for eating, grooming, dressing the upper body, dressing the lower body, and bathing at the time of discharge. When each FIM item score was ≥6 points, the subject was considered independent. One thousand bootstrap grip strength datasets for each independence and dependence in self-care activities were generated from the actual grip strength. Thereafter, we randomly assigned the total bootstrap datasets to 90% training and 10% testing datasets and inputted the bootstrap training data into a non-linear SVM. After training, we used the SVM algorithm to predict a testing dataset for cross-validation. This validation procedure was repeated 10 times.The SVM with grip strengths more accurately predicted independence or dependence in self-care activities than the chance level (mean ± standard deviation of accuracy rate: eating, 0.71 ± 0.04, P < .0001; grooming, 0.77 ± 0.03, P < .0001; upper-body dressing, 0.75 ± 0.03, P < .0001; lower-body dressing, 0.72 ± 0.05, P < .0001; bathing, 0.68 ± 0.03, P < .0001).Non-linear SVM based on grip strengths can prospectively predict self-care activities.

Effect of Prestroke Glycemic Variability Estimated Glycated Albumin on Stroke Severity and Infarct Volume in Diabetic Patients Presenting With Acute Ischemic Stroke

Background: We investigated whether prestroke glycemic variability, represented by glycated albumin (GA), affects the initial stroke severity and infarct volume in diabetic patients presenting with acute ischemic stroke. Methods: We evaluated a total of 296 acute ischemic stroke patients with diabetes mellitus who were hospitalized within 48 h of stroke onset. GA was measured in all acute ischemic stroke patients consecutively during the study period. The primary outcome was the initial National Institute Health Stroke Scale (NIHSS) score. The secondary outcome was infarct volume on diffusion-weighted imaging, which was performed within 24 h of stroke onset. Higher GA (≥16.0%) was determined to reflect glycemic fluctuation prior to ischemic stroke. Results: The number of patients with higher GA was 217 (73.3%). The prevalence of a severe initial NIHSS score (>14) was higher in patients with higher GA than in those with lower GA (3.8% vs. 15.7%, p = 0.01). The proportion of participants in the highest quartile of infarct volume was higher in the higher GA group (11.4% vs. 36.4%, p < 0.001). A multivariable analysis showed that higher GA was significantly associated with a severe NIHSS score (odds ratio, [95% confidence interval], 7.99 [1.75-36.45]) and large infarct volume (3.76 [1.05-13.45]). Conclusions: Prestroke glucose variability estimated by GA was associated with an increased risk of severe initial stroke severity and large infarct volume in acute ischemic stroke patients with diabetes mellitus.

The Effect of Metformin on Polycystic Ovary Syndrome in Overweight Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Metformin is an important component of PCOS treatment. At present, the effect of metformin in overweight women with PCOS has not been evaluated. Therefore, we conducted a systematic review to assess the effects of metformin in overweight women with PCOS and to analyze the effects of metformin in overweight women with PCOS.

METHODS

We searched the PubMed, Cochrane Library, Embase, CNKI, VIP, and Wanfang databases for studies published before March 2020. Randomized controlled trials were identified to study the effects of metformin in overweight women with PCOS. Data from studies including body mass index (BMI), waist circumference (WC), follicle-stimulating hormone (FSH), homeostasis model assessment of insulin resistance (HOMA-IR), luteinizing hormone (LH), sex hormone-binding globulin (SHBG), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, total cholesterol (TC), triglycerides (TG), fasting blood glucose (FBG), fasting insulin, testosterone, and androstenedione were pooled. Qualified trials were selected, and methodological quality was strictly assessed. Two reviewers chose the studies independently of each other.

RESULTS

Twelve trials were included. The intervention group and the control group had significant differences in the changes in body mass index (BMI) (WMD = -1.25, 95% CI (-1.60, -0.91), p < 0.00001) and waist circumference (WC) (WMD = -1.41, 95% CI (-2.46, -0.37), p=0.008) after metformin. The comprehensive results show that, in all studies, overweight women with polycystic ovary syndrome treated with metformin had significantly improved endocrine and metabolic indicators, including testosterone, follicle-stimulating hormone, luteinizing hormone, and low-density lipoprotein cholesterol. However, metformin did not regulate the secretion indexes of fasting insulin, homeostasis model assessment of insulin resistance, sex hormone-binding globulin, high-density lipoprotein cholesterol, total cholesterol, triglycerides, fasting blood glucose, and androstenedione.

CONCLUSIONS

Compared with control interventions, metformin appears to be an effective intervention for overweight women with PCOS.

Poststroke depression and risk of recurrent stroke: A meta-analysis of prospective studies

BACKGROUND

Conflicting results have been reported on the association of poststroke depression with recurrent stroke events. This meta-analysis of prospective studies aims to evaluate whether poststroke depression is an independent predictor of stroke recurrence among stroke patients.

METHODS

A systematic search of articles in PubMed and Embase databases from their inception to October 2018 was conducted. Prospective studies reporting risk estimates of stroke recurrence by depression status in stroke patients were included and pooled risk ratio (RR) with 95% confidence intervals (CIs) of stroke recurrence was calculated for patients with or without poststroke depression.

RESULTS

Six studies with 4648 stroke patients were finally included, and the prevalence of poststroke depression was found to from 15.9% to 40.5%. The pooled adjusted RR for stroke recurrence in patients suffering from poststroke depression was 1.48 (1.22-1.79) in a fixed-effect model. Subgroup analyses indicated that poststroke depression significantly increased stroke recurrence (RR 1.64; 95% CI, 1.28-2.10) among ischemic stroke patients but not in total stroke patients (RR 1.28; 95% CI, 0.96-1.73).

CONCLUSIONS

This meta-analysis suggests that poststroke depression may be an independent predictor of stroke recurrence among ischemic stroke patients. Further studies are required to investigate whether treatment of poststroke depression can reduce the risk of stroke recurrence.

Neuroinflammation and Microvascular Dysfunction After Experimental Subarachnoid Hemorrhage: Emerging Components of Early Brain Injury Related to Outcome

Aneurysmal subarachnoid hemorrhage has a high mortality rate and, for those who survive this devastating injury, can lead to lifelong impairment. Clinical trials have demonstrated that cerebral vasospasm of larger extraparenchymal vessels is not the sole contributor to neurological outcome. Recently, the focus of intense investigation has turned to mechanisms of early brain injury that may play a larger role in outcome, including neuroinflammation and microvascular dysfunction. Extravasated blood after aneurysm rupture results in a robust inflammatory response characterized by activation of microglia, upregulation of cellular adhesion molecules, recruitment of peripheral immune cells, as well as impaired neurovascular coupling, disruption of the blood-brain barrier, and imbalances in endogenous vasodilators and vasoconstrictors. Each of these phenomena is either directly or indirectly associated with neuronal death and brain injury. Here, we review recent studies investigating these various mechanisms in experimental models of subarachnoid hemorrhage with special emphasis on neuroinflammation and its effect on microvascular dysfunction. We discuss the various therapeutic targets that have risen from these mechanistic studies and suggest the utility of a multi-targeted approach to preventing delayed injury and improving outcome after subarachnoid hemorrhage.

Therapeutic effect of early intensive antihypertensive treatment on rebleeding and perihematomal edema in acute intracerebral hemorrhage

To observe the effect of early intensive blood pressure (BP)-lowering treatment on rebleeding and perihematomal edema (PE) in patients with acute intracerebral hemorrhage (ICH). A total of 121 patients with ICH were randomly assigned to an early intensive antihypertensive treatment group (IG) (n = 62) or control group (CG) (n = 59). For both groups, 25 mg of urapidil injection was slowly administered intravenously in 6 hours of the onset. For the IG, 100 mg of urapidil and 30 mL of 0.9% sodium chloride were then slowly administered. Repeat computed tomography imaging was performed at 24 hours, 72 hours, day 7, and day 14 to detect any rebleeding via changes in hematoma volume and the changes in PE. Finally, NIHSS scores and Barthel Index (BI) were calculated at 24 hours, 72 hours, day 7, day 14, day 30, and day 90. The average hematoma volume in IG patients was significantly smaller than that of CG patients after 24 hours (P < .05). The volume of PE in the CG increased more than in the IG within 24 hours of onset, but was not statistically significant (P > .05); however, this trend was statistically significant after 72 hours (P < .05). On day 30 and day 90, the average NIHSS score of IG patients was lower than that of CG patients, and the BI was higher (P < .05) than that of CG patients. There was no significant difference in mortality between the two groups. Early intensive antihypertensive treatment in ICH patients reduces rebleeding and PE, improving short-term quality of life.

Changes in Event-Related Potentials Underlying Coma Recovery in Patients with Large Left Hemispheric Infarction

<strong>BACKGROUND</strong> The aim of this study was to investigate changes in event-related potentials (ERPs) between coma and awakening in patients with large left hemispheric infarction (left LHI). <strong>MATERIAL AND METHODS</strong> Ten patients with left LHI who suffered coma and survived to awaken were enrolled in this study. The eye-opening subscore of the Glasgow Coma Scale (GCS) was used to assess the extent of patients' arousal. ERPs elicited by the passive oddball paradigm were collected during coma and awakening states, respectively. Peak latencies, peak amplitudes, topography, and time-frequency information of P1, N1, P2, and mismatch negativity (MMN) were compared between the 2 sessions. <strong>RESULTS</strong> No significant differences in the peak amplitudes and peak latencies of P1 and N1, but significantly greater P2 amplitude with shorter latency in left hemisphere and midline was shown in the awakening state compared with that in coma. A marked shift of P2 topography in response to deviant tones was also seen, from the right centro-parieto-frontal areas during coma to left frontal-midline areas during awakening. MMN waveforms were not detected in 6/10 patients during the coma state, but these 6 patients all recovered to awakening. Evoked oscillations in bilateral hemisphere were profoundly inhibited during the coma state, with poor inter-trial phase synchronization, while obvious activities with broader frequency ranges and consistent inter-trial phase synchronization were observed during awakening state, and different frequency activities were distributed in distinct brain regions. <strong>CONCLUSIONS</strong> P2 may be a central index of coma recovery and a component of the arousal system. Changes in time-frequency information could provide more information during coma recovery, perhaps including some cognitive processing of the sensory stimulus.

Prevalence of diabetes and its effects on stroke outcomes: A meta-analysis and literature review

AIMS/INTRODUCTION

Diabetes mellitus is an established risk factor for stroke and maybe associated with poorer outcomes after stroke. The aims of the present literature review were to determine: (i) the prevalence of diabetes in acute stroke patients through a meta-analysis; (ii) the association between diabetes and outcomes after ischemic and hemorrhagic stroke; and (iii) to review the value of glycated hemoglobin and admission glucose-based tests in predicting stroke outcomes.

MATERIALS AND METHODS

Ovid MEDLINE and EMBASE searches were carried out to find studies relating to diabetes and inpatient stroke populations published between January 2004 and April 2017. A meta-analysis of the prevalence of diabetes from included studies was undertaken. A narrative review on the associations of diabetes and different diagnostic methods on stroke outcomes was carried out.

RESULTS

A total of 66 eligible articles met inclusion criteria. A meta-analysis of 39 studies (n = 359,783) estimated the prevalence of diabetes to be 28% (95% confidence interval 26-31). The rate was higher in ischemic (33%, 95% confidence interval 28-38) compared with hemorrhagic stroke (26%, 95% confidence interval 19-33) inpatients. Most, but not all, studies found that acute hyperglycemia and diabetes were associated with poorer outcomes after ischemic or hemorrhagic strokes: including higher mortality, poorer neurological and functional outcomes, longer hospital stay, higher readmission rates, and stroke recurrence. Diagnostic methods for establishing diagnosis were heterogeneous between the reviewed studies.

CONCLUSIONS

Approximately one-third of all stroke patients have diabetes. Uniform methods to screen for diabetes after stroke are required to identify individuals with diabetes to design interventions aimed at reducing poor outcomes in this high-risk population.

Effect of Interventional Therapy on IL-1β, IL-6, and Neutrophil-Lymphocyte Ratio (NLR) Levels and Outcomes in Patients with Ischemic Cerebrovascular Disease

Background

This study investigated the clinical effect of interventional therapy in ischemic cerebrovascular disease (ICD).

Material/Methods

A retrospective analysis was performed on 260 ICD patients who were divided into a control group (122 patients, conventional drug treatment) and an observation group (138 patients, interventional therapy plus conventional drug treatment). Enzyme-linked immunosorbent assay was used to examine the expression of IL-1β, IL-6, and NLR. Furthermore, neurological deficit scores and Barthel index scores as well as the correlation of IL-1β, IL-6 and NLR were examined in these 2 groups.

Results

The expression of IL-1β, IL-6, and NLR significantly decreased in both groups after 1 week or 4 weeks of treatment compared with before treatment (P<0.05). Significant differences in neurological impairment scores were detected between these 2 groups after 4 weeks of treatment (P<0.05), and the control group showed higher neurological deficit scores than did the observation group (P<0.05). Barthel index scores were significantly higher after treatment than before treatment in the control and observation group (P<0.05), and the control group had lower Barthel index scores than did the observation group (P<0.05). Pearson correlation analysis showed that IL-1β, IL-6, and NLR expression were positively correlated in ICD patients (P<0.05).

Conclusions

Interventional surgery combined with conventional drug therapy can reduce serum IL-1β and IL-6 levels, decrease neurological impairment, and improve the quality of life of patients. The combined treatment group showed better outcomes than did the group that received the drug alone; therefore, combined therapy is suitable for promoting better clinical outcomes.

Relationship Between Glycated Haemoglobin and Carotid Atherosclerotic Disease Among Patients with Acute Ischaemic Stroke

Objectives

This study aimed to determine the relationship between glycaemic control and carotid atherosclerotic disease among patients with acute ischaemic stroke (AIS).

Methods

This retrospective cross-sectional study took place in the Neurology Department of King Fahad Hospital of University, Khobar, Saudi Arabia, from April to October 2017. Data were collected from the medical records of 244 patients with a diagnosis of AIS confirmed by computed tomography. Doppler ultrasounds of the carotid artery were performed to determine the presence of increased carotid intima media thickness (CIMT) and plaques.

Results

Significantly higher mean glycated haemoglobin (HbA1c) levels were noted in cases with high CIMT values (P = 0.002), but not in cases with carotid plaques (P = 0.360). In addition, there was a significant association between diabetes mellitus (DM) and high CIMT (P = 0.045), but not with carotid plaques (P = 0.075). Finally, while dyslipidaemia and age were independently correlated with high CIMT values (P = 0.034 and <0.001, respectively) and carotid plaques (P <0.001 each), no independent relationships were noted in terms of gender and other risk factors like DM, hypertension and smoking (P >0.050 each).

Conclusion

High HbA1c levels were associated with high CIMT values, but not with carotid plaques. Therefore, HbA1c levels may be useful as an indirect marker of the initial stages of carotid artery atherosclerosis.

Lymphocyte-to-Monocyte Ratio Is an Independent Predictor for Neurological Deterioration and 90-Day Mortality in Spontaneous Intracerebral Hemorrhage

BACKGROUND Lymphocyte-to-monocyte ratio (LMR) is an independent predictive factor of clinical outcome of acute ischemic stroke and cancer, but the predictive effect of LMR in spontaneous intracerebral hemorrhage (ICH) is unknown. Thus, the aim of this study was to explore the impact of peripheral LMR on the neurological deterioration (ND) during the initial week after spontaneous ICH onset, as well as 90-day mortality. MATERIAL AND METHODS The clinical data of 558 consecutive patients with ICH were retrospectively analyzed. LMR is calculated by absolute lymphocyte count divided by absolute monocyte count. RESULTS Of these patients, 166 patients experienced ND during the first week after admission and 72 patients died within 90 days. Multivariate analysis indicated that white blood cells (WBC), absolute neutrophil count (ANC), absolute lymphocyte count (ALC), neutrophil-to-lymphocyte ratio (NLR), LMR were significantly associated with ND during the initial week after ICH onset and also were associated with 90-day mortality. Moreover, NLR and LMR showed a higher predictive ability in ND during the initial week after ICH onset than 90-day mortality in receiver operating characteristic analysis. The best cut-off points of NLR and LMR in predicting ND and 90-day mortality were 10.24 and 2.21 and 16.81 and 2.19, respectively. CONCLUSIONS Our results suggest that LMR on admission is a predictive factor for ND during the initial week after ICH onset, as well as 90-day mortality.

Correlations of Acute Cerebral Hemorrhage Complicated with Stress Ulcer Bleeding with Acute Physiology and Chronic Health Evaluation (APACHE) II Score, Endothelin (ET), Tumor Necrosis Factor-alpha (TNF-α), and Blood Lipids

Background

This study investigated the correlations between acute cerebral hemorrhage complicated with stress ulcer bleeding and corresponding indexes, including the Acute Physiology and Chronic Health Evaluation (APACHE) II score, vascular endothelin-1 (ET-1), tumor necrosis factor-alpha (TNF-α), and blood lipid factors.

Material/Methods

A total of 53 patients with acute cerebral hemorrhage complicated with stress ulcer bleeding were selected as the observation group and 50 patients with simple acute cerebral hemorrhage were selected as the control group. The APACHE II score and the levels of ET-1, TNF-α, and blood lipid factors, including total cholesterol (TC), triglyceride (TG), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), and malondialdehyde (MDA), were detected and the correlations of were analyzed between the 2 groups of patients.

Results

The blood lipid index TG, APACHE II score, ET-1, TNF-α, renal function indexes [blood urea nitrogen (BUN) and creatinine (Cr)], mortality rate, hemoglobin, and MDA in the observation group were significantly higher than those in the control group, while HDL-C in the observation group was obviously lower than in the control group (p<0.05). The APACHEII score had positive correlations with TG and TNF-α (r=0.8960, r=0.8563, respectively), while it was negatively correlated with TC, HDL-C, LDL-C, and ET-1 (r=−0.909, r=−0.9292, r=−0.8543, and r=−0.8899, respectively) (p<0.001 in all comparisons). APACHEII score, BUN, and Cr were all risk factors.

Conclusions

Stress ulcer in patients with acute cerebral hemorrhage is associated with blood lipid changes and inflammation, which provides clues for the diagnosis and treatment of acute cerebral hemorrhage.

Neutrophil-to-Lymphocyte Ratio in Acute Cerebral Hemorrhage: a System Review

Spontaneous intracerebral hemorrhage (ICH) accounts for approximately 10 to 30% of all acute cerebrovascular events, and it is the type of stroke associated with the highest rates of mortality and residual disability. The inflammatory response is early triggered by hematoma components and can enhance the damage within the hemorrhagic brain. Assessment of peripheral biomarkers of inflammation could contribute to increase knowledge about some of the mechanisms involved in the ICH-induced injury and yield information on the disease course. The neutrophil-to-lymphocyte ratio (NLR) integrates information on both the innate and adaptive compartments of the immunity and represents a reliable measure of the inflammatory burden. The aim of the current review is to highlight the available evidence about the relationships between the NLR and clinical outcome in patients with acute ICH and provide critical insights into the underlying pathophysiology. Since no therapy targeting ICH-induced primary injury has yielded conclusive benefits and ICH treatment remains mainly supportive within a framework of general critical care management, these findings could also contribute to identify new potential targets for neuroprotection and develop novel therapeutic strategies.

Clinical Implications of Serial Glucose Measurements in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Serial glucose might more accurately reflect glycemic status in acute ischemic stroke (AIS) than presenting glucose. We sought to investigate the clinical implications of various parameters of serial glucose on the outcomes of patients with AIS treated with intravenous thrombolysis (IVT). This was a single-center, prospective, observational study of stroke patients treated with IVT. Blood glucose (BG) was serially measured at 6-time points during the first 24 h of IVT. The primary endpoint analyzed was a good outcome at 3 m. Among the 492 patients in the cohort (age, 70 ± 12 y; men, 57%), the overall BG level was 131 ± 33 mg/dl. At 3 m, 40.4% of the patients had a good outcome. Patients with good outcomes had significantly lower mean BG (121 vs 128 mg/dl) and higher coefficient of variance (CoV, 17% vs 14%) but no differences in the others. For patients with higher mBG (every 30 mg/dl), the likelihood of achieving a good outcome decreased (OR 0.82, 95% CI 0.67–1.02). For patients with higher CoV (every 10%), the likelihood of a good outcome increased (OR 1.38, 95% CI 1.12–1.71). The results showed that higher mBG and lower CoV were consistently associated with worse outcomes in IV-thrombolyzed stroke patients, suggesting that lowering BG might be potential therapeutic target.

Hemoglobin A1c predicts hemorrhagic transformation and poor outcomes after acute anterior stroke

BACKGROUND AND PURPOSE

Hemorrhagic transformation (HT) is a major complication of acute ischaemic stroke that is potentially related to clinical deterioration. The objective of this study was to assess whether chronic hyperglycemia is a predictive factor of HT in patients with acute anterior stroke.

METHODS

Patients with acute anterior stroke were included in this study. Hemoglobin A1c (HbA1c) was measured in the morning after hospitalization. HT was detected by computed tomography scans or gradient echo magnetic resonance imaging performed 4 (±2) days after onset. Univariate and multivariate logistic regression analyses were used to assess the risks for HT and short-term outcomes.

RESULTS

Of the 426 patients included, 93 (21.8%) had HT: 61 (14.3%) presented with hemorrhagic infarction and 32 (7.5%) presented with parenchymal hematoma. A total of 54 patients received thrombolytic treatment and 18 (33.3%) were found to have HT. In the multivariate analysis, HbA1c [odds ratio (OR), 1.294; 95% confidence interval (CI), 1.097-1.528], infarction size (OR, 3.358; 95% CI, 1.748-6.449) and thrombolytic therapy (OR, 3.469; 95% CI, 1.757-6.847) were predictors of HT. The predictive effect of HbA1c on HT was still observed in both groups when patients were stratified according to the levels of fasting blood glucose. HbA1c was found to be a predictor of poor outcomes in the multilogistic regression analysis (OR, 1.482; 95% CI, 1.228-1.788).

CONCLUSIONS

Higher HbA1c was independently related to HT and poor neurological outcomes in patients with ischaemic stroke. These findings have significant implications for the treatment of diabetes and glucose management in patients with diabetes mellitus and/or acute ischaemic stroke.

Twenty-four-hour blood pressure variability plays a detrimental role in the neurological outcome of hemorrhagic stroke

Background

Blood pressure variability (BPV) is a modifiable risk factor for stroke. This study was performed to determine the prognostic role of BPV in patients with acute hemorrhagic stroke.

Methods

The data of 131 hospitalized hypertensive patients with spontaneous intracerebral hemorrhage (sICH) were collected. All patients underwent examinations using several neurological scales (Glasgow Coma Scale, National Institutes of Health Stroke Scale, and modified Rankin scale [mRS]) and BP measurements at different time points.

Results

Sex, age, hematoma volume, and neurological scores were not significantly different between patients with a favorable and unfavorable prognosis for sICH. However, significant differences were found in hypertension, diabetes, metabolic syndrome, atrial fibrillation, smoking, and stroke history. The standard deviation (SD), coefficient of variation (CV), and maximum–minimum range (Max–Min) of diastolic BP and the mean, SD, CV, and Max–Min of systolic BP significantly differed between the groups. Statistical analysis also demonstrated correlations between the 90-day mRS score and BPV and between systolic BPV and the 90-day mRS score.

Conclusion

High systolic or diastolic BPV within 24 hours of hemorrhagic stroke onset is associated with the 90-day neurological prognosis. The 24-hour BPV plays a critical role in the neurological outcome of hemorrhagic stroke.

Embolic strokes of undetermined source in a cohort of Polish stroke patients

We aimed to provide a descriptive analysis of embolic stroke of undetermined etiology (ESUS) population based on a long-term prospective stroke registry. We retrospectively analyzed data collected in a detailed registry regarding consecutive patients admitted for first-ever ischemic stroke (IS) between January 2001 and December 2015. We used Org 10172 in Acute Stroke Treatment classification supplemented with ESUS criteria proposed by the Cryptogenic Stroke/ESUS International Working Group. Within the ESUS group, we additionally compared patients ≤ 60 and > 60 years of age. During the study period, there was a total of 3008 (1615 females and 1393 males) admissions of first-ever strokes. The most frequent cause was undetermined (38.7%), followed by cardioembolic (27.7%), large artery atherosclerosis (18.2%), small vessel disease (11.9%), and other determined (3.6%). We identified 326 patients as ESUS, which accounted for 10.8% of all strokes and 28% of strokes of undetermined etiology. ESUS patients were the youngest. Compared to all types of stroke but for those with small vessel disease, ESUS patients were most often independent before stroke and had the least severe neurological deficit at admission and the best outcome at discharge. ESUS patients ≤ 60 years were more frequently independent at discharge than ESUS patients > 60 years. Approximately 11% of patients from our registry met ESUS criteria. ESUS patients were younger when compared to all other stroke etiologies, suffered less severe strokes, and had more favorable outcome at discharge than other groups except for those with small vessel disease strokes.

Neutrophil-to-Lymphocyte Ratio Is an Independent Predictor of 30-Day Mortality of Intracerebral Hemorrhage Patients: a Validation Cohort Study

In a previous study in patients with intracranial hemorrhage (ICH), we found an association between high neutrophil-to-lymphocyte ratio (NLR) with poor short-term mortality. In the current study, this preliminary finding was validated using an independent patient cohort. A total of 181 ICH patients (from January 2016 to December 2017) were included. Diagnosis was confirmed using computed tomography (CT) in all cases. Patient survival (up to 30 days) was compared between subjects with high NLR (above the 7.35 cutoff; n = 74) versus low NLR (≤ 7.35; n = 107) using Kaplan-Meier analysis. A multivariate logistic regression was performed to identify factors that influenced the 30-day mortality. Correlation between NLR with other relevant factors (e.g., C-reactive protein (CRP) and fibrinogen) was examined using Spearman correlation analysis. The 30-day mortality was 19.3% (35/181) in the entire sample, 37.8% (28/74) in the high-NLR group, and 6.5% (7/107) in the low-NLR group (P < 0.001). In comparison to the low-NLR group, the high-NLR group had higher rate of intraventricular hemorrhage (29.7 vs. 16.8%), ICH volume (median 23.9 vs. 6.0 cm³) and ICH score (median 1.5 vs. 0), and lower GCS score (9.4 ± 4.5 vs. 12.9 ± 3.2). An analysis that divided the samples into three equal parts based on NLR also showed increasing 30-day mortality with incremental NLR (1.6, 15.0, and 41.7% from lowest to highest NLR tertile, P for trend < 0.001). Kaplan-Meier curve showed higher 30-day mortality in subjects with high NLR than those with low NLR (P < 0.001 vs. low-NLR group, log-rank test). High NLR (> 7.35) is associated with poor short-term survival in acute ICH patients.

Future challenges of stroke treatment

Posterior circulation stroke accounts for approximately 20% of all ischaemic strokes. Acute basilar artery occlusion (BAO) is one of the most severe conditions, it is associated with death or major disability in more than three quarters of the cases, and its optimal management remains unestablished. Currently, the treatment is based primarily upon consensus, the clinical practice varies widely, and the actual benefit of mechanical thrombectomy has to be fully estimated. Although the recent years have profoundly revolutionized and improved the stroke care, many questions still remain unanswered and will represent the challenges of the next future.

Neutrophil-to-lymphocyte ratio improves outcome prediction of acute intracerebral hemorrhage

BACKGROUND

The inflammatory response plays a role in determining the course of intra-cerebral hemorrhage (ICH) and immune parameters may have prognostic value. The aim of the study was to determine whether the peripheral leukocyte counts and neutrophil-to-lymphocyte ratio (NLR) were associated to 30-day functional status after ICH, and improved the accuracy of outcome prediction when added to the Modified ICH score.

METHODS

We retrospectively identified consecutive patients with spontaneous ICH who underwent blood sampling and cranial CT neuroimaging within 24 h from onset. Total white blood cells (WBC), absolute neutrophil count (ANC) and absolute lymphocyte count (ALC) were collected, and the NLR computed as the ANC to ALC ratio. The study endpoint was 30-day functional status; poor outcome was defined as death or major disability (modified Rankin Scale score ≥ 3).

RESULTS

Two hundred and eight patients were enrolled, of which 111 (53.4%) had a modified Rankin Scale score ≥ 3 at 30 days from ICH. At multivariate analysis, the WBC (adjusted odd ratio [_adjOR] for 1000 leukocytes increase 1.20, 95% confidence interval [CI] 1.05-1.38), ANC (_adjOR for 1000 neutrophils increase 1.34, 95% CI 1.14-1.57), ALC (_adjOR for 1000 lymphocytes increase 0.34, 95% CI 0.20-0.59) and NLR (_adjOR for 1-point increase 1.49, 95% CI 1.24-1.79) were independently associated with 30-day poor outcome. Predictive accuracy of the Modified ICH score was enhanced by adding the NLR.

CONCLUSIONS

The NLR was associated with 30-day mortality and morbidity after ICH, and improved the accuracy of outcome prediction when added to the Modified ICH score.

Up-regulation of angiotensin-converting enzyme in response to acute ischemic stroke via ERK/NF-κB pathway in spontaneously hypertensive rats

Cerebral ischemic stroke is usually caused by a temporary or permanent decrease in blood supply to the brain. Despite general progress in diagnosis and treatment, the prognosis of stroke is still unsatisfactory, and more detailed potential mechanisms are needed to investigate underlying the pathological process. Here, we showed that serum angiotensin-converting enzyme (ACE) concentration was positively correlated with infarct volume after acute ischemic stroke (AIS). Moreover, using a permanent middle cerebral artery occlusion rat model, we indicated for the first time that increased ACE expression in response to AIS was regulated by the ERK/NF-κB pathway in peri-infarct regions. More importantly, we disclosed that angiotensin II type 1 receptors were implicated in up-regulation of ACE expression in peri-infarct regions. These findings offer insight into ACE expression and activity in response to stroke, and further our understanding of ACE mechanisms.

Prognostic value of glucose metabolism for non-ST-segment elevation infarction patients with diabetes mellitus and single concomitant chronic total occlusion following primary percutaneous coronary intervention

Glucose metabolism status may play a predictive role in the severity of the complications among patients with type 2 diabetes mellitus (DM). However, few studies have focused on the prognostic value of glycosylated hemoglobin (HbA1c) and Homeostatic Model Assessment 2 for Insulin Resistance (HOMA2-IR) in patients with DM, non-ST-segment elevation infarction (NSTEMI), and single concomitant chronic total occlusion (CTO) following primary percutaneous coronary intervention (PCI). Short- and long-term prognostic value of HbA1c and HOMA2-IR in patients with DM with NSTEMI and single CTO who received primary percutaneous transluminal coronary intervention (pPCI).Data from 202 patients with NSTEMI and single CTO in nonculprit vessels were included. The incidence of revascularization, cardiogenic shock, ischemic stroke, major bleeding (ie, cerebral hemorrhage or massive hemorrhage of gastrointestinal tract), and cardiac death were combined as composite end points (CEPs). HbA1c was measured on admission and at 12 and 24 weeks after discharge. HOMA2-IR was measured on admission and at 6 and 12 weeks after discharge. The mean value of HbA1c and HOMA2-IR was calculated to determine the impact on 2.5-year CEPs. All patients were assessed during hospitalization and followed for up to 2.5 years after discharge.Mean age was 62.4 ± 11.8 years and 76% were male. Previous MI, lower left ventricular ejection fraction, and higher HbA1c (hazard ratio [HR] = 1.216; 95% confidence interval [CI] = 1.023-1.445; P = .023) were independently associated with a poor prognosis at 2.5 years. Higher HbA1c and HOMA2-IR on admission was associated with CEPs during hospitalization. Mean HOMA2-IR prior to pPCI was associated with revascularization (HR = 1.129; 95% CI = 1.008-1.265; P = .036) and ischemic stroke (HR = 1.276; 95% CI = 1.044-1.560; P = .017) during the 2.5 years follow-up period.Glucose metabolism status reflected by HbA1c and HOMA2-IR may provide prognostic value to patients with NSTEMI, type 2 DM, and single concomitant CTO following PCI. Therefore, patients with NSTEMI, CTO, and poor glycemic control should be carefully evaluated prior to PCI.