Prognostic implications of admission inflammatory profile in acute ischemic neurological events

Peripheral inflammatory response in people after acute ischaemic stroke and isolated spontaneous cervical artery dissection

The systemic inflammatory response following acute ischaemic stroke remains incompletely understood. We characterised the circulating inflammatory profile in 173 acute ischaemic stroke patients by measuring 65 cytokines and chemokines in plasma. Participants were grouped based on their inflammatory response, determined by high-sensitivity C-reactive protein levels in the acute phase. We compared stroke patients' profiles with 42 people experiencing spontaneous cervical artery dissection without stroke. Furthermore, variations in cytokine levels among stroke aetiologies were analysed. Follow-up samples were collected in a subgroup of ischaemic stroke patients at three and twelve months. Ischaemic stroke patients had elevated plasma levels of HGF and SDF-1α, and lower IL-4 levels, compared to spontaneous cervical artery dissection patients without stroke. Aetiology-subgroup analysis revealed reduced levels of nine cytokines/chemokines (HGF, SDF-1α, IL-2R, CD30, TNF-RII, IL-16, MIF, APRIL, SCF), and elevated levels of IL-4 and MIP-1β, in spontaneous cervical artery dissection (with or without ischaemic stroke as levels were comparable between both groups) compared to other aetiologies. The majority of cytokine/chemokine levels remained stable across the study period. Our research indicates that stroke due to large artery atherosclerosis, cardioembolism, and small vessel occlusion triggers a stronger inflammatory response than spontaneous cervical artery dissection.

From Admission to Discharge: Predicting National Institutes of Health Stroke Scale Progression in Stroke Patients Using Biomarkers and Explainable Machine Learning

As a result of social progress and improved living conditions, which have contributed to a prolonged life expectancy, the prevalence of strokes has increased and has become a significant phenomenon. Despite the available stroke treatment options, patients frequently suffer from significant disability after a stroke. Initial stroke severity is a significant predictor of functional dependence and mortality following an acute stroke. The current study aims to collect and analyze data from the hyperacute and acute phases of stroke, as well as from the medical history of the patients, in order to develop an explainable machine learning model for predicting stroke-related neurological deficits at discharge, as measured by the National Institutes of Health Stroke Scale (NIHSS). More specifically, we approached the data as a binary task problem: improvement of NIHSS progression vs. worsening of NIHSS progression at discharge, using baseline data within the first 72 h. For feature selection, a genetic algorithm was applied. Using various classifiers, we found that the best scores were achieved from the Random Forest (RF) classifier at the 15 most informative biomarkers and parameters for the binary task of the prediction of NIHSS score progression. RF achieved 91.13% accuracy, 91.13% recall, 90.89% precision, 91.00% f1-score, 8.87% FNrate and 4.59% FPrate. Those biomarkers are: age, gender, NIHSS upon admission, intubation, history of hypertension and smoking, the initial diagnosis of hypertension, diabetes, dyslipidemia and atrial fibrillation, high-density lipoprotein (HDL) levels, stroke localization, systolic blood pressure levels, as well as erythrocyte sedimentation rate (ESR) levels upon admission and the onset of respiratory infection. The SHapley Additive exPlanations (SHAP) model interpreted the impact of the selected features on the model output. Our findings suggest that the aforementioned variables may play a significant role in determining stroke patients' NIHSS progression from the time of admission until their discharge.

Personalised Approach to Diagnosing and Managing Ischemic Stroke with a Plasma-Soluble Urokinase-Type Plasminogen Activator Receptor

Background: The increasing incidence of ischemic stroke has led to the search for a novel biomarker to predict the course of disease and the risk of mortality. Recently, the role of the soluble urokinase plasminogen activator receptor (suPAR) as a biomarker and indicator of immune system activation has been widely examined. Therefore, the aim of the current study was to assess the dynamics of changes in serum levels of suPAR in ischemic stroke and to evaluate the prognostic value of suPAR in determining mortality risk. Methods: Eighty patients from the Department of Neurology, diagnosed with ischemic stroke, were enrolled in the study. Residual blood was obtained from all the patients on the first, third and seventh days after their ischemic stroke and the concentrations of suPAR and C-reactive protein (CRP), as well as the number of leukocytes and National Institute of Health’s Stroke Scale (NIHSS) scores, were evaluated. Results: On the first day of ischemic stroke, the average suPAR concentration was 6.55 ng/mL; on the third day, it was 8.29 ng/mL; on the seventh day, it was 9.16 ng/mL. The average CRP concentration on the first day of ischemic stroke was 4.96 mg/L; on the third day, it was 11.76 mg/L; on the seventh day, it was 17.17 mg/L. The number of leukocytes on the first day of ischemic stroke was 7.32 × 103/mm3; on the third day, it was 9.27 × 103/mm3; on the seventh day, it was 10.41 × 103/mm3. Neurological condition, which was assessed via the NIHSS, on the first day of ischemic stroke, was scored at 10.71 points; on the third day, it was scored at 12.34 points; on the seventh day, it was scored at 13.75 points. An increase in the values of all the evaluated parameters on the first, third and seventh days of hospitalisation was observed. The patients with hypertension, ischemic heart disease and type 2 diabetes showed higher suPAR and CRP concentrations at the baseline as well as on subsequent days of hospitalisation. The greatest sensitivity and specificity were characterised by suPAR-3, where a value above 10.5 ng/mL resulted in a significant increase in mortality risk. Moreover, an NIHSS-1 score above 12 points and a CRP-3 concentration above 15.6 mg/L significantly increased the risk of death in the course of the disease. Conclusions: The plasma suPAR concentration after ischemic stroke is strongly related to the patient’s clinical status, with a higher concentration on the first and third days of stroke resulting in a poorer prognosis at a later stage of treatment. Therefore, assessing the concentration of this parameter has important prognostic value.

Clinical profile and role of C-reactive protein and lactate dehydrogenase as prognostic marker and comparative efficacy of different pharmacotherapeutic agents in patients with cerebrovascular accident: An observational study

The current study was conducted to determine the role of C-reactive protein (CRP) and lactate dehydrogenase (LDH) as prognostic-marker and outcomes of different pharmacotherapeutic agents among patients with cerebrovascular accident (CVA). A hospital-based observational study was conducted and patients with CVA admitted were included. Serum-CRP on admission correlated positively with modified Rankin score (mRS) (r = 0.9, P < 0.001) in ischemic stroke, whereas no correlation between serum LDH with mRS (r = 0.1, P = 0.5) was observed. Neither CRP nor LDH was helpful in predicting the outcome in hemorrhagic stroke. The use of Vitamin B12 was associated with favorable outcome in ischemic CVA cases and use of folic acid was associated with favorable outcome among hemorrhagic-CVA patients.

Vascular endothelial dysfunction associated with severity in multiple sclerosis

BACKGROUND

Impairment of cerebrovascular reactivity (CVR) has been reported in patients with multiple sclerosis (MS). Chronic inflammation and endothelial dysfunction are possible mechanisms underlying this hemodynamic impairment. This study aimed to evaluate CVR and endothelial function in patients with MS and explore their relationships with disease progression using functional sonographic procedures.

METHODS

Patients with MS and age-/sex-matched healthy controls were assessed for endothelial function, determined by flow-mediated dilation (FMD), and CVR, measured using the breath-holding index (BHI).

RESULTS

Twenty-seven patients with MS and 24 healthy controls were enrolled. FMD was significantly lower in MS subjects than in control subjects (6.0 ± 0.6 vs. 8.6 ± 0.7, p = 0.006); furthermore, BHI was similarly lower in MS than in controls, but insignificant. Remarkably, FMD was significantly lower in secondary progressive MS subjects than in relapse-remitting MS subjects (3.7 ± 1.3 vs. 6.7 ± 0.7, p = 0.045). In addition, FMD was inversely correlated with the disability score as per the expanded disability status scale (R² = 0.170, p = 0.033) and modified Rankin scale (R² = 0.187, p = 0.027).

CONCLUSION

In patients with MS, endothelial dysfunction was more noticeable than CVR impairment, correlating with the severity and progression of MS.

Prognostic Hemostasis Biomarkers in Acute Ischemic Stroke

Supplemental Digital Content is available in the text.

Objectives—

The prediction of patients at risk for poor clinical outcome after acute ischemic stroke remains challenging. An imbalance of coagulation factors may play an important role in progression and prognosis of these patients. In this systematic review, we assessed the current literature on hemostasis biomarkers and the association with poor clinical outcome in acute ischemic stroke.

Approach and Results—

A systematic search of Embase, Medline, Cochrane Library, Web of Science, and Google Scholar was performed on studies reporting on hemostasis biomarkers and clinical outcome after acute ischemic stroke. Studies were considered eligible if blood samples were collected within 72 hours after symptom onset. Additionally, clinical outcome should be assessed using a disability score (Barthel Index or modified Rankin scale). Methodological quality of included studies was assessed with an adapted version of the Quality Assessment of Diagnostic Accuracy Studies questionnaire. A total of 80 articles were read full text, and 41 studies were considered eligible for inclusion, reporting on 37 different hemostasis biomarkers. No single biomarker appeared to be effective in predicting poor clinical outcome in acute ischemic stroke patients.

Conclusions—

Based on current literature, no clear recommendations can be provided on which hemostasis biomarkers are a predictor of clinical outcome after acute ischemic stroke. However, some biomarkers show promising results and need to be further investigated and validated in large populations with clear defined study designs.

Association of Neutrophil-to-Lymphocyte Ratio and Lymphocyte-to-Monocyte Ratio with Treatment Modalities of Acute Ischaemic Stroke: A Pilot Study

Background and Objectives: Ischaemic stroke (IS) is the leading cause of death and disability worldwide. All stages of cerebral ischaemia, but especially acute phase, are associated with inflammatory response. Recent studies showed that neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR) may be used to assess inflammation in IS. To test whether there is a relationship between these parameters and type of stroke treatment, we analysed NLR and LMR in IS patients treated with three different modalities. Materials and Methods: The study included 58 adults with acute IS. A total of 28 patients received intravenous thrombolysis. In another 10 patients, the thrombolytic therapy was followed by thrombectomy and 20 patients did not undergo causal treatment. Blood samples were obtained within 24 h of the stroke diagnosis to calculate NLR and LMR. Next, NLR and LMR of the study subgroups were compared. Results: Our study revealed that NLR was significantly higher in patients treated with thrombectomy following thrombolysis, compared to no causal treatment. Statistical analysis demonstrated that patients with high National Institutes of Health Stroke Scale (NIHSS) scores presented higher NLR than in those with low NIHSS scores. Additionally, patients with high-sensitivity C-reactive protein (hs-CRP) ≥ 3 mg/L presented with significantly higher NLR and significantly lower LMR than the group of patients with lower hs-CRP (<3 mg/L). Conclusions: The main finding of this pilot study was that NLR in IS patients treated using thrombectomy following thrombolysis was markedly higher than that in other treatment groups, which was associated with increased severity of the disease in these patients. Therefore, patients with higher NLR may be expected to have more severe stroke. The link between stroke severity and NLR deserves further study.

Quantitative Measurement of Erythrocyte Aggregation as a Systemic Inflammatory Marker by Ultrasound Imaging: A Systematic Review

This systematic review is aimed at answering two questions: (i) Is erythrocyte aggregation a useful biomarker in assessing systemic inflammation? (ii) Does quantitative ultrasound imaging provide the non-invasive option to measure erythrocyte aggregation in real time? The search was executed through bibliographic electronic databases CINAHL, EMB Review, EMBASE, MEDLINE, PubMed and the grey literature. The majority of studies correlated elevated erythrocyte aggregation with inflammatory blood markers for several pathologic states. Some studies used "erythrocyte aggregation" as an established marker of systemic inflammation. There were limited but promising articles regarding the use of quantitative ultrasound spectroscopy to monitor erythrocyte aggregation. Similarly, there were limited studies that used other ultrasound techniques to measure systemic inflammation. The quantitative measurement of erythrocyte aggregation has the potential to be a routine clinical marker of inflammation as it can reflect the cumulative inflammatory dynamics in vivo, is relatively simple to measure, is cost-effective and has a rapid turnaround time. Technologies like quantitative ultrasound spectroscopy that can measure erythrocyte aggregation non-invasively and in real time may offer the advantage of continuous monitoring of the inflammation state and, thus, may help in rapid decision making in a critical care setup.

Blood/Brain Biomarkers of Inflammation After Stroke and Their Association With Outcome: From C-Reactive Protein to Damage-Associated Molecular Patterns

Stroke represents one of the most important causes of disability and death in developed countries. However, there is a lack of prognostic tools in clinical practice to monitor the neurological condition and predict the final outcome. Blood biomarkers have been proposed and studied in this indication; however, no biomarker is currently used in clinical practice. The stroke-related neuroinflammatory processes have been associated with a poor outcome in stroke, as well as with poststroke complications. In this review, we focus on the most studied blood biomarkers of this inflammatory processes, cytokines, and C-reactive protein, evaluating its association with outcome and complications in stroke through the literature, and performing a systematic review on the association of C-reactive protein and functional outcome after stroke. Globally, we identified uncertainty with regard to the association of the evaluated biomarkers with stroke outcome, with little added value on top of clinical predictors such as age or stroke severity, which makes its implementation unlikely in clinical practice for global outcome prediction. Regarding poststroke complications, despite being more practical scenarios in which to make medical decisions following a biomarker prediction, not many studies have been performed, although there are now some candidates for prediction of poststroke infections. Finally, as potential new candidates, we reviewed the pathophysiological actions of damage-associated molecular patterns as triggers of the neuroinflammatory cascade of stroke, and their possible use as biomarkers.

Inflammatory and metabolic markers and short-time outcome in patients with acute ischemic stroke in relation to TOAST subtypes

The aim of this study was to evaluate the association between inflammatory and metabolic markers and short-time outcome with acute ischemic stroke subtypes. A total of 121 patients was classified according to TOAST criteria, such as large artery atherosclerosis (LAAS), lacunar infarct (LAC), cardioembolic infarct (CEI), other determined etiology (ODE), and undetermined etiology (UDE). The functional impairment was evaluated within the first eight hours of stroke and the outcome after three-month follow-up using the modified Rankin Scale. Blood samples were obtained up to 24 h of stroke. Compared with 96 controls, patients with LAAS, CEI, and LAC subtypes showed higher levels of white blood cells, high-sensitivity C-reactive protein (hsCRP), interleukin 6 (IL-6), metalloproteinase 9 (MMP-9), glucose, and iron (p < 0.05); and lower high-density lipoprotein cholesterol (HDL-C) (p < 0.0001); platelets, insulin, insulin resistance, and homocysteine were higher in LAC (p < 0.0001); ferritin was higher in LAAS (p < 0.0001); and total cholesterol (TC) was lower in LAAS and CEI (p < 0.01). When stroke subtypes were compared, insulin was higher in LAAS vs. LAC and in LAC vs. CEI (p < 0.05); and TC was lower in LAAS vs. LAC (p < 0.05). Outcome and rate of mortality after three-month were higher in LAAS vs. LAC (p < 0.001 and p = 0.0391 respectively). The results underscored the important role of the inflammatory response and metabolic changes in the pathogenesis of ischemic stroke subtypes that might be considered on the initial evaluation of stroke patients to identify those that could benefit with individualized therapeutic strategies that taken into account these markers after acute ischemic event.

Crosstalk between red blood cells and the immune system and its impact on atherosclerosis

Atherosclerosis is a chronic multifactorial disease of the arterial wall characterized by inflammation, oxidative stress, and immune system activation. Evidence exists on a pathogenic role of oxidized red blood cells (RBCs) accumulated in the lesion after intraplaque hemorrhage. This review reports current knowledge on the impact of oxidative stress in RBC modifications with the surface appearance of senescent signals characterized by reduced expression of CD47 and glycophorin A and higher externalization of phosphatidylserine. The review summarizes findings indicating that oxidized, senescent, or stored RBCs, due to surface antigen modification and release of prooxidant and proinflammatory molecules, exert an impaired modulatory activity on innate and adaptive immune cells and how this activity contributes to atherosclerotic disease. In particular RBCs from patients with atherosclerosis, unlike those from healthy subjects, fail to control lipopolysaccharide-induced DC maturation and T lymphocyte apoptosis. Stored RBCs, accompanied by shedding of extracellular vesicles, stimulate peripheral blood mononuclear cells to release proinflammatory cytokines, augment mitogen-driven T cell proliferation, and polarize macrophages toward the proinflammatory M1 activation pathway. Collectively, literature data suggest that the crosstalk between RBCs with immune cells represents a novel mechanism by which oxidative stress can contribute to atherosclerotic disease progression and may be exploited for therapeutic interventions.

Risk factors and biomarkers of ischemic stroke in cancer patients

BACKGROUND AND PURPOSE

Stroke is common among cancer patients. However, risk factors and biomarkers of stroke in cancer patients are not well established. This study aimed to investigate risk factors and biomarkers as well as etiology of ischemic stroke in cancer patients.

METHODS

A retrospective review was conducted in cancer patients with ischemic stroke who were admitted to a general hospital in Busan, Korea, between January 2003 and December 2012. The risk factors and biomarkers for stroke and stroke subtypes in cancer patients were compared with age- and sex-matched noncancer patients with ischemic stroke who were admitted to the same hospital during the same period.

RESULTS

One hundred fifty-six cancer patients with ischemic stroke were identified. Cancer patients with ischemic stroke were found to have a significantly lower proportion of hypertension, atrial fibrillation, hyperlipidemia, and ischemic heart disease than noncancer patients with ischemic stroke. However, stroke biomarkers, such as erythrocyte sedimentation rate and high-sensitivity C-reactive protein, fibrinogen, pro-brain natriuretic peptide, and D-dimer levels, were significantly increased in cancer patients with ischemic stroke than in noncancer patients. Large-artery atherosclerosis and stroke of undetermined cause were more common in cancer patients with ischemic stroke than in noncancer patients with ischemic stroke.

CONCLUSIONS

Cancer patients with ischemic stroke showed different risk factors, stroke biomarkers, and stroke etiology compared with noncancer patients with ischemic stroke.

Can high-sensitivity C-reactive protein and ferritin predict functional outcome in acute ischemic stroke? A prospective study

BACKGROUND

Inflammation may not only be the consequence of brain infarction but it may also contribute to ischemic damage. However, the role of inflammatory markers in predicting functional outcome in stroke remains controversial.

OBJECTIVE

This study was conducted to evaluate the predictive value of admission high-sensitivity C-reactive protein (hs-CRP) and ferritin levels for functional disability in patients with acute ischemic stroke at 3-month follow-up and investigate the relationship between inflammatory markers and subtypes, severity, and risk factors of ischemic stroke.

METHODS

Sixty-two patients were examined prospectively within 48 hours after onset of ischemic stroke. Plasma hs-CRP and ferritin measurements were obtained from patients within 48 hours after onset and at 3-month follow-up. Patients were divided into 2 groups based on the level of hs-CRP: elevated (serum hs-CRP ≥0.5 mg/dL) and normal (serum hs-CRP<0.5 mg/dL) hs-CRP groups. Stroke severity was analyzed by the National Institutes of Health Stroke Scale (NIHSS) and functional disability was assessed by the Functional Independence Measure (FIM) and Functional Ambulation Scale (FAS). Stroke subtypes were classified according to the Oxfordshire Community Stroke Project.

RESULTS

Except for the correlation between hs-CRP levels and FIM scores on admission, no significant correlation was found between laboratory markers and FIM, FAS, and NIHSS scores and stroke subtypes on admission and at 3-month follow-up (P ≯ .05).

CONCLUSION

This study revealed that neither hs-CRP nor ferritin levels could predict functional disability 3 months after stroke onset. FIM, FAS, and NIHSS scores were more useful in predicting functional outcome 3 months after stroke onset than the laboratory markers evaluated in this study.

C-reactive protein and long-term ischemic stroke prognosis

C-reactive protein (CRP) is an inflammatory biomarker of inflammation and may reflect progression of vascular disease. Conflicting evidence suggests CRP may be a prognostic biomarker of ischemic stroke outcome. Most studies that have examined the relationship between CRP and ischemic stroke outcome have used mortality or subsequent vascular event as the primary outcome measure. Given that nearly half of stroke patients experience moderate to severe functional impairments, using a biomarker like CRP to predict functional recovery rather than mortality may have clinical utility for guiding acute stroke treatments. The primary aim of this study was to systematically and critically review the relationship between CRP and long-term functional outcome in ischemic stroke patients to evaluate the current state of the literature. PubMed and MEDLINE databases were searched for original studies which assessed the relationship between acute CRP levels measured within 24 hours of symptom onset and long-term functional outcome. The search yielded articles published between 1989 and 2012. Included studies used neuroimaging to confirm ischemic stroke diagnosis, high-sensitivity CRP assay, and a functional outcome scale to assess prognosis beyond 30 days after stroke. Study quality was assessed using the REMARK recommendations. Five studies met all inclusion criteria. Results indicate a significant association between elevated baseline high sensitivity CRP and unfavorable long-term functional outcome. Our results emphasize the need for additional research to characterize the relationship between acute inflammatory markers and long-term functional outcome using well-defined diagnostic criteria. Additional studies are warranted to prospectively examine the relationship between high sensitivity CRP measures and long-term outcome.

High-sensitivity C-reactive protein is a strong risk factor for death after acute ischemic stroke among Chinese

BACKGROUND AND PURPOSE

Elevated plasma C-reactive protein (CRP) has been suggested as a risk factor for ischemic stroke (IS) and coronary ischemic disease. Evidence has shown that high-sensitivity CRP (hs-CRP) is related to a worsening prognosis after IS, but hs-CRP was rare in a large-sample study in a Chinese population. We investigated the associations between hs-CRP and outcome of Chinese patients after acute IS.

METHODS

Seven hundred and forty-one consecutive acute IS patients (74.9% male, mean age 60.9 years), with baseline characteristics and hs-CRP measured within 24 h after hospitalization, were admitted in this study. We also prospectively followed up for clinical outcome and death 3 months after disease onset. hs-CRP was divided into two categories: hs-CRP >3 mg/L and hs-CRP ≤3 mg/L. Survival analysis using multivariable Cox regression was performed to analyze the association between hs-CRP and stroke outcomes after adjusting for potential confounding factors.

RESULTS

Compared with low hs-CRP, patients with high hs-CRP (>3 mg/L) had a significantly higher rate of all-cause death (0.71% vs. 10.00%; P < 0.001) at 3 months after stroke onset. High hs-CRP was an independent risk factor for all-cause death (HR, 6.48; 95% CI, 1.41 to 29.8; P= 0.016), as well as history of atrial fibrillation (HR, 5.24; 95% CI, 1.83 to 15.0; P= 0.002), no statin therapy during hospitalization (HR, 4.56; 95% CI, 2.18 to 9.55; P < 0.001), high homocysteine (>15.1 mmol/L) (HR, 2.66; 95% CI, 1.26 to 5.60; P= 0.01); fasting glucose (>6.1 mmol/L) (HR, 9.14; 95% CI, 3.34 to 25.0; P < 0.001), NIHSS at admission (HR, 2.35; 95% CI, 1.35 to 4.09; P= 0.003) and history of coronary heart disease (CHD) (HR, 2.34; 95% CI, 1.06 to 5.17; P= 0.035). Kaplan-Meier survival curves showed a higher risk of death for patients with hs-CRP >3 mg/L (P= 0.016).

CONCLUSION

Elevated plasma hs-CRP independently predicted risk of all-cause death within 3 months after acute IS in Chinese patients.

Admission C-reactive protein after acute ischemic stroke is associated with stroke severity and mortality: the 'Bergen stroke study'

Background

There is growing evidence that inflammation plays an important role in atherogenesis. Previous studies show that C-reactive protein (CRP), an inflammatory marker, is associated with stroke outcomes and future vascular events. It is not clear whether this is due a direct dose-response effect or rather an epiphenomenon. We studied the effect of CRP measured within 24 hours after stroke onset on functional outcome, mortality and future vascular events.

Methods

We prospectively studied 498 patients with ischemic stroke who were admitted within 24 hours after the onset of symptoms. CRP and NIH stroke scale (NIHSS) were measured at the time of admission. Short-term functional outcome was measured by modified Rankin scale (mRS) and Barthel ADL index (BI) 7 days after admission. Patients were followed for up to 2.5 years for long-term mortality and future vascular events data.

Results

The median CRP at admission was 3 mg/L. High CRP was associated with high NIHSS (p = 0.01) and high long-term mortality (p < 0.0001). After adjusting for confounding variables, high CRP remained to be associated with high NIHSS (p = 0.02) and high long-term mortality (p = 0.002). High CRP was associated with poor short-term functional outcomes (mRS > 3; BI < 95) (p = 0.01; p = 0.03). However, the association was not significant after adjusting for confounding variables including stroke severity (p = 0.98; p = 0.88). High CRP was not associated with future vascular events (p = 0.98).

Conclusion

Admission CRP is associated with stroke severity and long-term mortality when measured at least 24 hours after onset. There is a crude association between high CRP and short-term functional outcome which is likely secondary to stroke severity. CRP is an independent predictor of long-term mortality after ischemic stroke.

RBC NOS: regulatory mechanisms and therapeutic aspects

Nitric oxide (NO), one of the most important vascular signaling molecules, is primarily produced by endothelial NO synthase (eNOS). eNOS is tightly regulated by its substrate l-arginine, cofactors and diverse interacting proteins. Interestingly, an NO synthase (NOS) was described within red blood cells (RBC NOS), and it was recently shown to significantly contribute to the intravascular NO pool and to regulate physiologically relevant mechanisms. However, the regulatory mechanisms and clinical implications of RBC NOS are unknown. The aim of this review is to highlight intracellular RBC NOS interactions and the role of RBC NOS in RBC homeostasis. Furthermore, macro- and microvascular diseases affected by RBC-derived NO are discussed.

C-reactive protein and fibrinogen in acute stroke patients with and without sleep apnea

BACKGROUND AND PURPOSE

Although sleep apnea (SA) is a risk factor for ischemic stroke and an important prognosticator in affected patients, the exact pathophysiological link between SA and stroke remains to be established. We investigated whether levels of C-reactive protein (CRP) and fibrinogen are increased in patients with acute stroke and SA compared with stroke patients without SA.

PATIENTS AND METHODS

117 consecutive patients with ischemic stroke admitted to our stroke unit within 12 h after stroke onset were included in this study. On admission, CRP and fibrinogen levels were determined. All patients received cardiorespiratory polygraphy during the first 72 h of their hospital stay. In all patients, demographic data, National Institutes of Health Stroke Scale score and cerebrovascular risk factors were assessed.

RESULTS

SA defined by an apnea-hypopnea index (AHI) of > or =10/h was found in 64 (55%) patients. Elevated CRP and fibrinogen levels were seen twice as often in patients with SA than in patients without (CRP: 52 vs. 26%; fibrinogen: 72 vs. 37%). After multivariate logistic regression analysis, an AHI of > or =10/h was independently correlated with raised levels of both of these parameters.

CONCLUSION

SA is independently associated with raised levels of CRP and fibrinogen in patients with acute ischemic stroke. We assume that both proteins are part of the pathophysiological pathway linking SA to stroke.

Increased plasma fibrinogen predicts one-year mortality in patients with acute ischemic stroke

BACKGROUND AND PURPOSE

Increased plasma fibrinogen is a risk factor for vascular diseases related to atherosclerosis. Its long-term predictive value in stroke survivors is not established. We conducted this study to establish the significance of hyperfibrinogenemia as the possible predictor of 30-day and one-year mortality in patients with acute ischemic stroke.

METHODS

We studied 900 unselected patients with ischemic stroke admitted to the hospital within 24 h after onset of symptoms. We noted demographic data, risk factors for stroke, neurological deficit and disturbances of consciousness on admission. We measured plasma concentration of fibrinogen and the body temperature on day 1 and registered vital status at 1, 3, 6 and 12 months after stroke.

RESULTS

Mean concentration of plasma fibrinogen was 2.9 g/L and 25.2% of patients had increased plasma concentration of fibrinogen (i.e. > or = 3.5 g/L) on day 1. Patients with hyperfibrinogenemia were more likely to die after 1, 3, 6 and 12 months than those with normal plasma fibrinogen (21.1% vs. 15.6%, 36.4% vs. 24.6%, 42.6% vs. 27.3%, 45.7% vs. 31.2%, respectively; P < 0.001 for the last three differences). Hyperfibrinogenemia did not predict short-term case-fatality, but increased concentration of plasma fibrinogen was an independent predictor of one-year case-fatality (P = 0.013; OR: 1.69 (95% CI 1.12-2.55)). Other independent predictors of one-year case-fatality were: neurological deficit on admission, age, white blood cell count, and body temperature on day 1.

CONCLUSIONS

Increased concentration of plasma fibrinogen shortly after ischemic stroke independently increases risk of death within one year after stroke.

Use of nebulized budesonide in two critical patients with hydrocarbon intoxication

Reports of acute naphtha (a petroleum distillate) intoxication, particularly those containing treatment and toxicological data, are poorly verified in the literature. Systemic steroids have not usually been advised for routine management, but no previous studies have been reported on the effects of corticosteroid inhalations. In this study, two critical pediatric patients with chemical pneumonia due to naphtha ingestion have been reported who were effectively managed with nebulized budesonide.

Plasma levels of lipophilic antioxidant vitamins in acute ischemic stroke patients: correlation to inflammation markers and neurological deficits

OBJECTIVES

Acute ischemic stroke is a clinical condition accompanied by inflammation and oxidative stress. In this study, we compared levels of plasma lipophilic antioxidants and inflammation markers between patients with stroke and healthy controls and assessed the associations of antioxidants, inflammation markers, and neurologic deficits among patients with stroke.

METHODS

We measured plasma levels of lipophilic antioxidant vitamins (retinol, lycopene, alpha-carotene, beta-carotene, alpha-tocopherol, and gamma-tocopherol), inflammation markers (high-sensitivity C-reactive protein [hs-CRP], fibrinogen, erythrocyte sedimentation rate, and white blood cell count), and neurologic deficits (indicated by the score of the National Institute of Health Stroke Scale) in 68 patients with acute ischemic stroke within 48 h after stroke onset in comparison with 41 normal controls.

RESULTS

Plasma alpha- and beta-carotene concentrations were lower and levels of inflammation markers were higher among patients with acute ischemic stroke compared with normal controls. Levels of alpha- and beta-carotene in patients with stroke were negatively associated with hs-CRP level (R = -0.29 and -0.41, respectively, P < 0.01) and with neurologic deficits (R = -0.28 and -0.27, respectively, P < 0.05). The negative association between neurologic deficits and combined plasma levels of alpha- and beta-carotene remained after adjustment for age and sex (P = 0.04). However, the magnitude of association decreased after adjustment of hs-CRP (P = 0.08).

CONCLUSION

Plasma concentrations of alpha- and beta-carotene are lower in patients with acute ischemic stroke than in healthy controls and are negatively correlated with hs-CRP level and neurologic deficits. The negative association between neurologic deficits and combined plasma alpha- and beta-carotene levels is confounded by hs-CRP.

Prognostic role of C-reactive protein in very old patients with acute ischaemic stroke

BACKGROUND AND SCOPE

Recent literature has demonstrated that inflammation contributes to all phases of atherosclerosis and brain damage caused by stroke. In acute phase of cerebrovascular diseases biochemical markers of inflammation, such as C-reactive protein (CRP), could represent an indicator of severity of stroke, but few studies have verified this hypothesis, especially in very old patients. The aim of this study was to evaluate the role of CRP on short- and long-term prognosis in 75-year old and over elderly patients with acute ischaemic stroke.

MATERIALS AND METHODS

We retrospectively evaluated CRP values (nephelometric method), performed within 12 h from hospital admission, in 196 elderly patients (124 females and 72 males with mean age+/-SD 83.32+/-10.46 years), discharged with diagnosis of acute ischaemic stroke, 68 of them with atherothrombotic large vessel stroke, 38 with lacunar stroke and 90 with cardioembolic stroke. We studied the relationship between CRP values and short-term prognosis [30-day mortality, length of hospitalization (LOS) and physical disability measured by modified Rankin scale and long-term prognosis (12-month mortality and re-hospitalization)].

RESULTS

Mean values of CRP were significantly higher in patients with cardioembolic stroke compared with atherothrombotic large vessel and lacunar stroke, in patients who died in the first 30 days from the acute event compared with survivors. LOS and physical disability score rose with increasing values of CRP for all subtypes of stroke. Higher CRP values were associated with the 12-month re-hospitalization for cerebrovascular events, whereas it did not influence the 12-month cumulative re-hospitalization and 12-month mortality.

CONCLUSIONS

Elevation of CRP values at hospital admission could represent a negative prognostic index in elderly patients with ischaemic stroke, in particular, for short-term prognosis.

The Erythrosense as a Real-Time Biomarker to Reveal the Presence of Enhanced Red Blood Cell Aggregability in Atherothrombosis

This paper reviews the longitudinal studies in which the association between hypertension and cognitive functioning has been explored. The findings of these studies are far from being consistent: positive, adverse, or no relationships between cognitive performance and blood pressure have been reported. In some studies, cognitive functioning was related only to systolic blood pressure, whereas in others, it was related to diastolic blood pressure alone. Most probably, the inconsistency is due to the variability in research design, the measures employed, and data management. Some of the main methodological issues are the wide range in the age of the subjects and the variability in hypertension at baseline. Length of exposure to hypertension was rarely considered, and the search for the possible effects of the different antihypertensive treatments on cognitive ability is in its infancy. Many studies seek to identify cognitively impaired elderly and do not distinguish between the different types of dementia or the different cognitive domains. Thus, the possibility that hypertension affects specific cognitive functions has not been explored. The use of subdivisions of blood pressure values may have obscured nonlinear relationship. Nevertheless, the pattern that emerges is that midlife hypertension enhances cognitive impairment later in life, but at old age, mild hypertension may increase cognitive performance. Directions for future research to further elucidate the complex relationship between age, blood pressure, and cognition are discussed.

The Erythrosense as a Real-Time Biomarker to Reveal the Presence of Enhanced Red Blood Cell Aggregability in Atherothrombosis

Both anemia and inflammation might be present in individuals with atherothrombosis. We have evaluated the eventual influence of these 2 variables on the degree of erythrocyte adhesiveness/aggregation in the peripheral blood of 583 women and 402 men with various atherothrombotic risk factors and vascular events. It turned out that both anemia and inflammation (highly sensitive C-reactive protein concentrations) influence the degree of cell adhesiveness/aggregation and that there is no interaction between them. Thus, the degree of erythrocyte adhesiveness/aggregation might have the diagnostic advantage of being enhanced in individuals with atherothrombosis who have inflammation and no anemia as well as those who have anemia and no inflammation. These findings might help to turn a phenomenon of hemorheological relevance into a diagnostic tool for the detection of individuals at risk of an acute ischemic event.

The Erythrosense as a Real-Time Biomarker to Reveal the Presence of Enhanced Red Blood Cell Aggregability in Atherothrombosis

A common mode of deep vein thrombosis prophylaxis in medical inpatients is unfractionated heparin 5000 U subcutaneously (s.q.) twice daily. We examined the evidence in favor of using this dose of heparin in this group of patients. MEDLINE was searched for studies using the words deep vein thrombosis prophylaxis and heparin. All randomized controlled trials comparing heparin and placebo or heparin and a low molecular weight heparin were used. Relative risk was 0.4 (95% confidence interval 0.22-0.73) in studies comparing heparin 5000 U s.q. b.i.d. with placebo. Relative risk was 0.28 (95% confidence interval 0.21-0.38) in studies comparing heparin 5000 units s.q. t.i.d. versus placebo. In studies comparing unfractionated heparin with enoxaparin relative risk was 1.42 (95% confidence interval 0.99-2.05). Heparin 5000 U s.q. b.i.d. is less efficacious than low molecular weight heparins and unfractionated heparin 5000 U s.q. t.i.d.

Assessment of relations between clinical outcome of ischemic stroke and activity of inflammatory processes in the acute phase based on examination of selected parameters

BACKGROUND AND PURPOSES

Inflammatory factors play an important role in the pathogenesis of ischemic stroke. They may influence circulation during the acute phase of stroke and enhance the ischemic region.

MATERIALS AND METHODS

We examined 51 patients--36 patients in the early stage of stroke, i.e. the first 24 h after onset. Of these, 15 patients had infection and 21 had no infection during the week preceding stroke. There were 15 patients with noninflammatory diseases in the control group. We analyzed parameters of inflammation such as: activity of serum chitotriosidase by fluorimetric assay, C-reactive proteins (CRP), number of white body cells (WBCs), IgG and fibrinogen. We also assessed the neurological stage according to the Scandinavian Stroke Scale (SSS).

RESULTS

In our study, we observed a statistically significant difference (p < 0.05) in the activity of most parameters of inflammation. This difference could be seen in the levels of CRP, number of WBCs and the activity of chitotriosidase, apart from IgG and fibrinogen, between the control group and groups with versus without infection. A significantly increased level of CRP (p < 0.0005) and fibrinogen (p > 0.01) was found on the first day in the stroke group as compared to the control group. The neurological stage on day 4 after stroke, assessed according to the SSS, was significantly worse in the group of patients with infection before stroke than in stroke patients without infection (p < 0.008).

CONCLUSION

These results suggest the importance of active inflammatory processes in the pathogenesis of stroke. We observed increased activity of chitotioridase, a parameter of the inflammatory process, in stroke. This study is one more proof that inflammatory processes caused by infection may influence the occurrence of stroke and worsen its outcome. It could be another step towards understanding immunological processes during the acute phase of stroke. The study may also help establish new diagnostic and therapeutic strategies and could be a useful tool for prophylaxis.

Inflammation-sensitive proteins and erythrocyte aggregation in atherothrombosis

OBJECTIVE

To find the relative contribution of various inflammation-sensitive proteins including fibrinogen, immunoglobulins (IgG, IgM and IgA), ceruloplasmin and high sensitivity C-reactive protein (hs-CRP) to the induction and/or maintenance of enhanced erythrocyte adhesiveness/aggregation in the peripheral blood of individuals with atherothrombotic risk factors.

METHODS

The degree of erythrocyte adhesiveness/aggregation was determined by a simple slide test and image analysis. In addition, we measured various inflammation-sensitive protein levels including fibrinogen, ceruloplasmin, immunoglobulins and hs-CRP in a group of 234 individuals with atherothrombotic risk factors and healthy ones. Pearson partial correlations and multiple linear regression analysis were performed.

RESULTS

Fibrinogen was found to be the major protein contributing to the enhanced erythrocyte adhesiveness/aggregation, explaining 30% of the model. Fibrinogen and IgG together explained 32.4% of the model. Other inflammation-sensitive proteins did not reach statistical significance and were excluded from the model.

CONCLUSIONS

Among inflammation-sensitive proteins measured in our cohort, fibrinogen is the dominant contributor to erythrocyte adhesiveness/aggregation in the peripheral blood of individuals with atherothrombotic risk factors and healthy ones. These findings may pave the way for the development of therapeutic strategies directed at the attenuation of erythrocyte aggregability in individuals with atherothrombosis.

C-reactive protein and white blood cell count increases in the first 24 hours after acute stroke

Levels of C-reactive protein (CRP) and white blood cell count (WBC) in acute stroke may reflect the stroke lesion itself or pre-existing factors such as infections, smoking or atherosclerosis. The aim of this study was to investigate the relation between CRP and WBC levels and time from onset of stroke, stroke severity and outcome.

PATIENTS AND METHODS

The analyses were based on 719 patients in whom WBC test material was obtained within 9 h of stroke onset and CRP test material within 24 h of stroke onset. Stroke severity was assessed by the Scandinavian Stroke Scale Score on admission and outcome by death 7 days, 3 months and 1 year after symptom onset as well as modified Rankin Scale 3 months after stroke onset.

RESULTS

CRP and WBC levels correlated significantly with time from symptom onset as well as with stroke severity and outcome. Levels of CRP and WBC were higher in later determinations in severe stroke. In multivariate logistic regression analysis, CRP(+10 mg/l) was independently related to 1-year mortality (OR 1.1, 95% CI 1.02-1.2).

CONCLUSION

Levels of WBC and CRP increase within the first 24 h in patients with severe stroke. CRP but not WBC is related to long-term mortality possibly by reflecting the vascular risk profile.

Sex differences in the expression of haemorheological determinants in individuals with atherothrombotic risk factors and in apparently healthy people

BACKGROUND

Increased red cell aggregation can be detrimental, leading to slow capillary blood flow and tissue hypoxaemia. Sex differences in the degree of erythrocyte adhesiveness/aggregation in the peripheral blood have not been clearly shown.

OBJECTIVES

To determine whether there are sex differences in the expression of erythrocyte adhesiveness/aggregation in the peripheral blood in individuals with atherothrombotic risk factors and in apparently healthy people.

METHODS

From a cohort of 965 participants in the Tel Aviv Medical Centre inflammation survey, 192 pairs of different sex were matched for age, body mass index, hip and waist circumferences, cardiovascular risk factors, and the intake of active cardiovascular drugs.

RESULTS

Women had an enhanced degree of red cell aggregation (p < 0.0005) as well as increased concentrations of inflammation sensitive proteins including fibrinogen and C reactive protein. Women had a lower haemoglobin concentration than men, but this did not affect the degree of erythrocyte adhesiveness/aggregation.

CONCLUSIONS

The significant increase in red blood cell adhesiveness/aggregation in the peripheral blood of women with atherothrombosis could be relevant to the more eventful course that some women experience during and following acute ischaemic disease.

Inflammation at a glance: erythrocyte adhesiveness/aggregation test to reveal the presence of inflammation in people with atherothrombosis

The erythrocyte adhesiveness/aggregation test is a new biomarker to detect low-grade inflammation in patients with atherothrombosis. In a group of 30 individuals with an acute ischemic event, the variability of EAAT during a follow-up period was similar to those obtained for other commonly used markers of the acute phase response, suggesting the potential clinical use of this novel marker.