Reduced frequency of high cholesterol levels among patients with intracerebral haemorrhage

Traditional and Non-Traditional Lipid Parameters in Relation to Parenchymal Hemorrhage Following Endovascular Treatment for Acute Ischemic Stroke in Anterior Circulation

Purpose

Lipid-lowering therapy is integral in acute ischemic stroke (AIS), yet the connection between lipid parameters and parenchymal hemorrhage (PH) after endovascular treatment (EVT) for AIS is not well-defined. This research aims to assess the association between various lipid parameters and the PH risk following EVT.

Patients and Methods

We examined a database of patients who underwent EVT for AIS between September 2021 and May 2023 retrospectively. Traditional and non-traditional lipid parameters were documented. PH was identified on dual energy computed tomography images within 48 h. We employed logistic regression analysis and restricted cubic splines to examine the association between various lipid parameters and the risk of PH. The predictive capacity of the lipid parameters for PH was evaluated by comparing the area under the curve.

Results

The study included 384 patients, 65 of whom (17.7%) developed PH. After adjusting for potential confounders, only triglyceride was associated with PH among the traditional lipid parameters, while all non-traditional lipid parameters were related to PH. Based on ROC curve, the ratio of remnant cholesterol to high-density lipoprotein cholesterol (RC/HDL-C) exhibited the highest predictive capability for PH. Furthermore, our analysis revealed a significant nonlinear correlation between triglyceride, non-high-density lipoprotein cholesterol, RC, RC/HDL-C and PH risk.

Conclusion

In assessing the risk of PH after EVT, non-traditional lipid parameters are often superior to traditional lipid parameters. It is recommended that routine evaluation of non-traditional lipid parameters could also be conducted in clinical practice as well.

Nomogram to predict hemorrhagic transformation for acute ischemic stroke in Western China: a retrospective analysis

Background and purpose

Hemorrhagic transformation (HT) is the most alarming complication of acute ischemic stroke. We aimed to identify risk factors for HT in Chinese patients and attempted to develop a nomogram to predict individual cases.

Methods

A retrospective study was used to collect the demographic and clinical characteristics of ischemic stroke patients at the Second Affiliated Hospital of Chongqing Medical University (development cohort) and Chongqing Sanbo Changan Hospital (validation cohort) from October 2013 to August 2020. Univariate analysis and multivariate analysis were used to identify the risk factors of patients in the development cohort. The nomogram was generated, and internal validation was performed. We used the area under the receiver-operating characteristic curve (AUC-ROC) to assess the discrimination and used the Hosmer–Lemeshow test to calibrate the model. To further verify the predictability and accuracy of the model, we performed an external validation of the patients in the validation cohort.

Results

A total of 570 patients were used to generate the nomogram. After univariate analysis and multivariate logistic regression, the remaining 7 variables (diabetes mellitus, atrial fibrillation, total cholesterol, fibrous protein, cerebral infarction area, NIHSS score and onset-to-treatment) were independent predictors of HT and used to compose the nomogram. The area under the receiver-operating characteristic curve of the model was 0.889 (95% CI, 0.841–0.938), and the calibration was good (P = 0.487 for the Hosmer–Lemeshow test). The model was validated externally with an AUC-ROC value of 0.832 (95% CI, 0.727–0.938).

Conclusions

The nomogram prediction model in this study has good predictive ability, accuracy and discrimination, which can improve the diagnostic efficiency of HT in patients with acute ischemic stroke.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02678-2.

Reduction in the Ratio of Low-density Lipoprotein Cholesterol to Highdensity Lipoprotein Cholesterol is Associated with Increased Risks of Hemorrhagic Transformation in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Hemorrhagic transformation (HT) is a potentially serious complication in patients with acute ischemic stroke (AIS). Whether the ratio of low-density lipoprotein cholesterol to high-density lipoprotein cholesterol (LDL-C/HDL-C) is associated with HT remains unclear.

METHODS

Ischemic stroke patients within 7 days of stroke onset from January 2016 to November 2017 were included in this study. Lipid profiles were measured within 24h after admission. HT was determined by a second computed tomography or magnetic resonance imaging within 7 days after admission. Univariate and multivariate logistic regression analysis was used to assess the association between LDL-C/HDL-C and HT.

RESULTS

We enrolled 1239 patients with AIS (788 males; mean age, 64 ± 15 years), of whom 129 (10.4%) developed HT. LDL-C/HDL-C was significantly lower on admission in patients with HT than those without HT (2.00 ± 0.89 vs. 2.25 ± 1.02, P=0.009). The unadjusted odds ratio (OR) of low LDL-C/HDL-C for HT was 2.07 (95% confidence interval [CI] 1.42-3.01, P＜0.001). After adjustment for possible confounders, lower LDL-C/HDL-C (≤1.52) was significantly associated with HT (OR 1.53, 95% CI: 1.02-2.31, P=0.046). Similar results were observed between lower LDL-C (≤ 4 mmol/L) and HT (OR 4.17, 95% CI: 1.25-13.90, P=0.02). However, no significant association was found between HT and high HDL-C, low triglycerides or low total cholesterol.

CONCLUSION

Lower LDL-C/HDL-C and LDL-C were significantly associated with increased risk of HT after AIS. Further investigations are warranted to confirm these findings and then optimize lipid management in stroke patients with lower LDL/HDL-C or LDL-C.

Comprehensive analysis of perforator territory infarction on postoperative diffusion-weighted imaging in patients with surgically treated unruptured intracranial saccular aneurysms

OBJECTIVE

Perforator territory infarction (PTI) is still a major problem needing to be solved to achieve good outcomes in aneurysm surgery. However, details and risk factors of PTI diagnosed on postoperative MRI remain unknown. The authors aimed to investigate the details of PTI on postoperative diffusion-weighted imaging (DWI) in patients with surgically treated unruptured intracranial saccular aneurysms (UISAs).

METHODS

The data of 848 patients with 1047 UISAs were retrospectively evaluated. PTI was diagnosed on DWI, which was performed the day after aneurysm surgery. Clinical and radiological characteristics were compared between UISAs with and without PTI. Poor outcome was defined as an increase in 1 or more modified Rankin Scale scores at 12 months after aneurysm surgery.

RESULTS

Postoperative DWI was performed in all cases, and it revealed PTI in 56 UISA cases (5.3%). Forty-three PTIs occurred without direct injury and occlusion of perforators (43 of 56, 77%). Poor outcome was more frequently observed in the PTI group (17 of 56, 30%) than the non-PTI group (57 of 1047, 5.4%) (p < 0.0001). Thalamotuberal arteries (p < 0.01), lateral striate arteries (p < 0.01), Heubner's artery (p < 0.01), anterior median commissural artery (p < 0.05), terminal internal carotid artery perforators (p < 0 0.01), and basilar artery perforator (p < 0 0.01) infarctions were related to poor outcome by adjusted residual analysis. On multivariate analysis, statin use (OR 10, 95% CI, 3.3-31; p < 0.0001), specific aneurysm locations (posterior communicating artery [OR 4.1, 95% CI 2.1-8.1; p < 0.0001] and basilar artery [OR 3.1, 95% CI 1.1-8.9; p = 0.031]), larger aneurysm size (OR 1.1, 95% CI 1.1-1.2; p = 0.043), and permanent decrease of motor evoked potential (OR 38, 95% CI 3.1-468; p = 0.0045) were related to PTI.

CONCLUSIONS

Despite efforts to avoid PTI, it occurred even without direct injury, occlusion of perforators, or evoked potential abnormality. Therefore, surgical treatment of UISAs, especially with the aforementioned risk factors of PTI, should be more carefully considered. The evaluation of PTI in the territory of the above-mentioned perforators could be useful in helping predict the clinical course in patients after aneurysm surgery.

Association between non-high-density lipoprotein cholesterol and haemorrhagic transformation in patients with acute ischaemic stroke

BACKGROUND

It is unclear whether non-high-density lipoprotein cholesterol (Non-HDL-C) is associated with haemorrhagic transformation (HT) after acute ischaemic stroke (AIS). We aimed to explore the association between Non-HDL-C and HT, as well as compare the predictive values of Non-HDL-C and low-density lipoprotein cholesterol (LDL-C) for HT.

METHODS

We consecutively enrolled AIS patients within 7 days of stroke onset. Participants were divided into four categories according to quartiles of Non-HDL-C. HT was assessed by follow-up brain imaging. We assessed the association between Non-HDL-C, LDL-C and HT in multivariate logistic regression analysis.

RESULTS

A total of 2043 patients were included, among whom 232 were identified as HT. Compared with the highest quartiles, the first, second and third quartiles of Non-HDL-C were associated with increased risk of HT (adjusted odds ratios [ORs] 1.74 [95% confidence interval [CI] 1.09-2.78], 2.01[95% CI 1.26-3.20], and 1.76 [95% CI 1.10-2.83], respectively, P for trend = 0.024). Similar results were found for LDL-C. There was significant interaction between Non-HDL-C and age (P for interaction = 0.021). The addition of Non-HDL-C and LDL-C to conventional factors significantly improved predictive values [Non-HDL-C, net reclassification index (NRI) 0.24, 95%CI 0.17-0.31, P < 0.001; LDL-C, NRI 0.15, 95%CI 0.08-0.22, P = 0.03].

CONCLUSIONS

Low Non-HDL-C was associated with increased risks of HT. In addition, Non-HDL-C has similar effects as LDL-C for predicting HT.

Statin, cholesterol, and sICH after acute ischemic stroke: systematic review and meta-analysis

BACKGROUND AND PURPOSE

Conflicts exist regarding relationship between prior/new statin use, cholesterol, and early poststroke intracranial hemorrhage (ICH) in acute ischemic stroke (AIS) patients. This meta-analysis is aimed at evaluating the safety of prior/new statin use, cholesterol level and risk of ICH in AIS patients.

METHODS

We searched PubMed and Embase for studies examining relation between statin use, cholesterol level, and early poststroke ICH in AIS. Included studies should report risk of early poststroke symptomatic ICH (sICH) or overall ICH. A random-effects model was used to pool the data.

RESULTS

Twenty-five articles involving 26,327 participants were included, among whom 925 had sICH. Prior statin use was not associated with overall ICH (adjusted odds ratio (OR), 1.478; 95% confidence interval (CI), 0.924-2.362; p = 0.103) and sICH in patients who received thrombolysis (adjusted OR, 1.567; 95% CI, 0.994-2.471; p = 0.053) or overall ICH in patients, most of whom had not received recanalization therapy (crude OR, 1.342; 95% CI, 0.872-2.065; p = 0.181). New statin use was associated with decreased sICH after recanalization therapy (crude OR, 0.292; 95% CI, 0.168-0.507; p < 0.001).Cholesterol level was not associated with overall ICH.

CONCLUSION

Prior/new statin use and lower cholesterol level are not risk factors for sICH and overall ICH in AIS patients, whether or not the patient has received recanalization therapy. New statin use is likely associated with decreased sICH.

Analysis for risk factors of 12-month neurological worsening in patients with surgically treated small-to-moderate size unruptured intracranial aneurysms

The risk associated with surgical treatment for small-to-moderate size unruptured intracranial aneurysms (SMUIAs, defined as <15 mm) has not been well characterized. Authors aimed to investigate risk factors for poor outcome in surgical treatment of SMUIAs. The data of prospectively collected 801 consecutive patients harboring 971 surgically treated SMUIAs was evaluated. Neurological worsening (NW) was defined as an increase in 1 or more modified Rankin Scale at 12-month. Clinical and radiological characteristics were compared. Neurological worsening was observed in 45 (4.6%). In multivariate analysis, only perforator territory infarction (PTI) on postoperative diffusion-weighted imaging (odds ratio (OR), 13; 95% confidence interval (CI), 4.9-32, p < 0.0001), and aneurysm locations (paraclinoid (OR, 6.9; 95% CI, 3.1-15, p < 0.0001), basilar artery (OR, 4.5; 95% CI, 1.5-14, p = 0.008), vertebral artery (OR, 11; 95% CI, 3.3-34, p < 0.0001)) were related to neurological worsening. Multivariate analysis showed that statin use (OR, 12; 95% CI, 3.8-39, p < 0.0001) and aneurysm locations (internal carotid artery-posterior communicating artery (OR, 3.9; 95% CI, 1.8-8.2, p < 0.0001) and basilar artery (OR, 6.3; 95% CI, 2.3-17, p = 0.008)), and aneurysm size >10 mm (OR, 5.3; 95% CI, 1.8-15, p = 0.003) were related to PTI. Although all SMUIAs should be carefully considered whether to be treated, those with statins, specific locations, and larger sizes should perhaps be more meticulously contemplated, and neurosurgeons should continue to avoid PTI.

Hemorrhagic transformation after cerebral infarction: current concepts and challenges

Hemorrhagic transformation (HT) is a frequent complication of acute ischemic stroke that is especially common after thrombolytic therapy. The risk of HT limits the applicability of tissue plasminogen activator (tPA). Here, we sought to review the rate, classification, predictors, possible mechanism, and clinical outcomes of HT, as well as existing therapeutic approaches, in order to call attention to the current challenges in the treatment of this complication.

Apolipoprotein E, statins, and risk of intracerebral hemorrhage

BACKGROUND AND PURPOSE

Apolipoprotein E (ApoE) genotypes have been associated with lobar intracerebral hemorrhage (ICH). Although statins have been associated with an increased risk of ICH, meta-analyses have not consistently shown a statin-induced risk of ICH. Here, we test whether hypercholesterolemia (HC) and ApoE polymorphisms affect the risk of ICH by statin use.

METHODS

The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS) study is a prospective, demographically matched case-control study of ICH. A similar study of ICH, Genetic Risks for Medication-Related Hemorrhagic Stroke (GOCHA), was used as a replication cohort. Subjects were classified as normocholesterolemia, HC without statin use, and HC with statin use. Statistical comparisons were performed using Fisher exact test, χ2 tests, and the Breslow-Day test.

RESULTS

The discovery cohort consisted of 558 ICH cases and 1444 controls, and the replication cohort consisted of 1020 ICH cases and 382 controls. The association of lower risk for HC was not attenuated by statin use. Statin use was observed to confer a higher risk for lobar ICH in those carrying ApoE4/E4 and ApoE2/E4 genotypes in both discovery and replication cohorts, and a test for interaction showed a trend towards significance (P=0.11 for statin and ApoE4/E4).

CONCLUSIONS

Statin use does not seem to attenuate the association of HC with decreased risk for nonlobar ICH. Our data support a gene-by-drug effect for lobar ICH, but larger sample sizes are needed to confirm the association before any clinical change is warranted.

CLINICAL TRIAL REGISTRATION URL

http://clinicaltrials.gov. Unique identifier: NCT00930280.

Low level of low-density lipoprotein cholesterol increases hemorrhagic transformation in large artery atherothrombosis but not in cardioembolism

BACKGROUND AND PURPOSE

Low cholesterol level is known to be associated with increased cerebral hemorrhage. However, the associations of hemorrhagic transformation (HTf) after acute ischemic stroke and the low levels of total cholesterol (TC) or low-density lipoprotein cholesterol (LDLC) are largely undiscovered.

METHODS

Of the 1034 patients with acute ischemic stroke who were consecutively admitted to our hospital, 377 patients with stroke attributable to large artery atherothrombosis (LAA; n=210) or cardioembolism (n=167) were selected for this study. Demographic and clinical information was collected and HTf was evaluated through follow-up T2*-weighted gradient-echo MRI performed usually within 1 week after stroke. Measurement of lipid parameters included TC, LDLC, high-density lipoprotein cholesterol, and triglyceride.

RESULTS

Of the 377 patients, HTf was noted in 74 patients (19.6%). When patients were divided into 4 groups according to their TC and LDLC levels, the incidence of HTf was significantly elevated in the lowest quartile of each TC (P<0.01) and LDLC (P<0.01) level in LAA subgroup, but not in cardioembolism. After adjusting covariates, a low level of LDLC (OR, 0.46 per 1 mmol/L-increase; 95% CI, 0.22-0.98) was independently associated with HTf in LAA, but not in cardioembolism. There was no significant association between low levels of TC (OR, 0.63 per 1 mmol/L-increase; 95% CI, 0.35-1.15) and HTf in LAA.

CONCLUSIONS

Low levels of LDLC, and possibly TC, are associated with greater risk of hemorrhagic transformation after acute ischemic stroke attributable to LAA.

Risk factors for primary intracerebral hemorrhage in patients in Izumo City, Japan

The annual incidence rate of primary intracerebral hemorrhage (ICH) in Izumo City, Japan, appears to be the highest rate among those reported. Despite improvement of management and surgical therapy, the overall morbidity and mortality after ICH are still high. The author investigated the risk factors for ICH in patients in Izumo. A case-control study of 242 patients (137 men and 105 women with ages ranging from 34 to 97 years) with primary ICH was conducted in Izumo between 1991 and 1998. Hypertension, diabetes mellitus, heart disease, liver disease, alcohol consumption, cigarette smoking, and serum levels of total cholesterol, aspartate aminotransferase, and alanine aminotransferase were assessed as possible risk factors for ICH by using conditional logistic regression. The prevalence of hypertension among ICH patients was 77% and the odds ratio (OR) for hypertension was 17.07 (95% CI: 8.30-35.09), which are much higher than figures reported from Western countries. The OR for hypertension was higher in individuals < or = 69 years of age than in those > or = 70 years of age and lower for lobar hemorrhage than for hemorrhages at other sites. High serum total cholesterol (> or = 220 mg/dl) was the second most important risk factor for ICH (OR: 2.52; 95% CI: 1.23-5.14), and low total cholesterol (< 160 mg/dl) decreased the risk of ICH (OR: 0.47; 95% CI: 0.27-0.82). In contrast, heart disease decreased the risk of ICH, and there was no observed association between alcohol consumption, cigarette smoking, or diabetes mellitus and ICH. This study conducted in Izumo suggests that hypertension is the most important risk factor for ICH and contrary to most previous studies indicates that serum total cholesterol concentration is also positively associated with the risk of ICH. In contrast, heart disease may decrease the risk of ICH.