Fibrinogen concentration and risk of ischemic stroke and acute coronary events in 5113 patients with transient ischemic attack and minor ischemic stroke

Potentially causal association between immunoglobulin G N-glycans and cardiometabolic diseases: Bidirectional two-sample Mendelian randomization study

BACKGROUND

Observational studies support that altered immunoglobulin G (IgG) N-glycosylation and inflammatory factors are associated with cardiometabolic diseases (CMDs); nevertheless, the causality between them remains unclear.

METHODS

Two-sample Mendelian randomization (MR) analyses were conducted to systematically investigate the bidirectional causality between IgG N-glycans and nine CMDs in both East Asians and Europeans.

RESULTS

In the forward MR analysis, the univariable MR analysis presented suggestive causality of 14 and eight genetically instrumented IgG N-glycans with CMDs in East Asians and Europeans, respectively; the multivariable MR analysis showed that ten and 11 pairs of glycan-CMD associations were identified in East Asian and European populations, respectively. In the reverse MR analysis, based on East Asians and Europeans, the univariable MR analysis presented suggestive causality of seven and 12 genetically instrumented CMDs with IgG N-glycans, respectively; the multivariable MR analysis presented that six and five CMD-glycan causality were found in East Asian and Europeans, respectively.

CONCLUSIONS

The comprehensive MR analyses provide suggestive evidence of bidirectional causality between IgG N-glycans and CMDs. This work helps to understand the molecular mechanism of the occurrence/progression of CMDs, optimize existing and develop new strategies to prevent CMDs, and contribute to the early identification of high-risk groups of CMDs.

Plasma fibrinogen and risk of vascular recurrence after ischaemic stroke: An individual participant and summary-level data meta-analysis of 11 prospective studies

INTRODUCTION

Inflammation is an emerging target for secondary prevention after stroke and randomised trials of anti-inflammatory therapies are ongoing. Fibrinogen, a putative pro-inflammatory marker, is associated with first stroke, but its association with major adverse cardiovascular events (MACE) after stroke is unclear.

MATERIALS AND METHODS

We did a systematic review investigating the association between fibrinogen and post-stroke vascular recurrence. Authors were invited to provide individual-participant data (IPD) and where available we did within-study multivariable analyses with adjustment for cardiovascular risk factors and medications. Adjusted summary-level data was extracted from published reports from studies that did not provide IPD. We pooled risk ratios (RR) by random-effects meta-analysis by comparing supra-median with sub-median fibrinogen levels and performed pre-specified subgroup analysis according to timing of phlebotomy after the index event.

RESULTS

Eleven studies were included (14,002 patients, 42,800 follow-up years), of which seven provided IPD. Fibrinogen was associated with recurrent MACE on unadjusted (RR 1.35, 95% CI 1.17-1.57, supra-median vs sub-median) and adjusted models (RR 1.21, 95% CI 1.06-1.38). Fibrinogen was associated with recurrent stroke on univariate analysis (RR 1.19, 95% CI 1.03-1.39), but not after adjustment (RR 1.11, 95% CI 0.94-1.31). The association with recurrent MACE was consistently observed in patients with post-acute (⩾14 days) fibrinogen measures (RR 1.29, 95% CI 1.16-1.45), but not in those with early phlebotomy (<14 days) (RR 0.98, 95% CI 0.82-1.18) (Pinteraction = 0.01). Similar associations were observed for recurrent stroke.

DISCUSSION AND CONCLUSION

Fibrinogen was independently associated with recurrence after stroke, but the association was modified by timing of phlebotomy. Fibrinogen measurements might be useful to identify patients who are more likely to derive benefit from anti-inflammatory therapies after stroke.

Efficacy and safety of batroxobin in patients with acute ischemic stroke: A multicenter retrospective analysis

AIMS

The objective of this study was to evaluate the effectiveness of batroxobin in improving functional outcomes and reducing stroke recurrence among patients with acute ischemic stroke beyond the therapeutic time window for thrombolytic therapy.

METHODS

This multicenter, retrospective study enrolled 492 patients with acute moderate-to-severe ischemic stroke within 24 h. 238 patients were given standard (basic) therapy. On the basis of standard treatment, 254 patients received an initial intravenous infusion of batroxobin 10 U on day 1, followed by subsequent infusions of batroxobin 5 U on the 3rd and 5th days, respectively.

RESULTS

In the batroxobin group, 8.3% of patients experienced recurrence stroke, compared to 17.2% in the control group (HR, 0.433; 95% CI, 0.248 to 0.757; p = 0.003). Furthermore, intravenous batroxobin significantly improved the distribution of 90-120 day disability. Moderate-to-severe bleeding events were reported in three patients (1.2%) in the batroxobin group and one patient (0.4%) in the control group (p = 0.369).

CONCLUSIONS

Among patients with acute moderate-to-severe ischemic stroke beyond the time window for thrombolytic therapy, treatment with intravenous batroxobin had a lower risk of stroke recurrence and a better recovery of function outcome without increasing bleeding events. Prospective studies are needed to further confirm.

Whole Blood Viscosity and Cerebral Blood Flow in Acute Ischemic Stroke

Existing effective treatments for ischemic stroke restore blood supply to the ischemic region using thrombolysis or mechanical removal of clot. However, it is increasingly recognized that successful removal of occlusive thrombus from the large artery-recanalization, may not always be accompanied by successful restoration of blood flow to the downstream tissues-reperfusion. Ultimately, brain tissue survival depends on cerebral perfusion, and a functioning microcirculation. Because capillary diameter is often equal to or smaller than an erythrocyte, microcirculation is largely dependent on erythrocyte rheological (hemorheological) factors such as whole blood viscosity (WBV). Several studies in the past have demonstrated elevated WBV in stroke compared with healthy controls. Also, elevated WBV has shown to be an independent risk factor for stroke. Elevated WBV leads to endothelial dysfunction, decreases nitric oxide-dependent flow-mediated vasodilation, and promotes hemostatic alterations/thrombosis, all leading to microcirculation sludging. Compromised microcirculation further leads to decreased cerebral perfusion. Hence, modulating WBV through pharmacological agents might be beneficial to improve cerebral perfusion in stroke. This review discusses the effect of elevated WBV on endothelial function, hemostatic alterations, and thrombosis leading to reduced cerebral perfusion in stroke.

Seasonal variation and prognosis in patients with acute myocardial infarction complicated by cardiogenic shock

Background

Little is known about the association between seasonal variation and prognosis in patients with CS caused by AMI.

Objectives

We investigated the 12-month clinical outcomes in patients treated with percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) according to season.

Methods

A total of 695 patients undergoing PCI for AMI complicated by CS was enrolled from 12 centers in South Korea. The study patients were divided into four groups according to season in which the AMI with CS occurred (spring, n = 178 vs. summer, n = 155 vs. autumn, n = 182 vs. winter, n = 180). We compared major adverse cardiovascular events (MACEs; the composite of cardiac death, myocardial infarction, re-hospitalization due to heart failure, and any revascularization) between the four groups.

Results

The risk of MACE during the 12 months after CS was similar in the four groups: spring, 68 patients, vs. summer, 69, vs. autumn, 73, vs. winter, 68 (p = 0.587). Multivariate Cox-regression analysis revealed no significant difference in 12-month MACE among groups compared to the spring group after inverse probability of treatment weighting adjustment (summer, HR 1.40, 95 % CI 0.98-1.99, p = 0.062; autumn, HR 1.26, 95 % CI 0.89-1.80, p = 0.193; winter, HR 1.18, 95 % CI 0.83-1.67, p = 0.356). The similarity of MACE between the four groups was consistent across a variety of subgroups.

Conclusions

After adjusting for baseline differences, seasonal variation seems not to influence the mid-term risk of 12-month MACE in patients treated with PCI for AMI complicated by CS.

Condensed abstract

Data are limited regarding the association between seasonal variation and prognosis in patients with cardiogenic shock (CS) caused by AMI. This study divided patients undergoing PCI for AMI complicated by CS into four groups based on the season of occurrence and found no significant differences in 12-month MACE between the groups after adjusting for bias and confounding factors. Multivariate analysis revealed consistent MACE similarity across subgroups. The study suggests that seasonal variation has no impact on the mid-term risk of 12-month MACE in patients with CS caused by AMI, after adjusting for baseline differences.

Trial registration

ClinicalTrials.gov NCT02985008RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock), NCT02985008, Registered December 5, 2016 - retrospectively and prospectively.

Irb information

This study was approved by the institutional review board of Samsung Medical Center (Reference number: 2016-03-130).

Diagnostic performance of plasma D-dimer, fibrinogen, and D-dimer to fibrinogen ratio as potential biomarkers to predict hypertension-associated acute ischemic stroke

Background

Ischemic stroke is a common type of stroke that leads to death and functional disability in hypertensive patients. However, there are no well-studied non-invasive and less expensive fluid biomarkers routinely used to detect ischemic stroke in hypertensive patients. Hence, this study aimed to tease out the performance of D-dimer, fibrinogen, and the D-dimer to fibrinogen ratio (DDFR) in predicting hypertension-associated acute ischemic stroke.

Methods

A hospital-based cross-sectional study was done from October 2022 to January 2022 at Yikatit 12 Hospital Medical College, Ethiopia. We recruited 55 hypertensive patients who had an ischemic stroke and 110 who did not. A ROC curve was used to calculate the areas under the curves (AUCs) and determine the diagnostic power of the D-dimer, fibrinogen, and DDFR. The Youden index was used to find the best cut-off points for biomarkers in detecting acute ischemic stroke. A De Long test was employed to show whether there was a significant difference between the AUCs of biomarkers in diagnosing ischemic stroke.

Results

D-dimer yielded the highest diagnostic power (AUC = 0.776) in detecting acute ischemic stroke, followed by DDFR (AUC = 0.763) and fibrinogen (AUC = 0.694), but there was no significant difference between them. At 0.52 μg/ml cut-off point, D-dimer had 82.9% sensitivity, 66.7% specificity, 62.5% PPV, and 85.3% NPV to diagnose acute ischemic stroke. Fibrinogen could detect acute ischemic stroke at 405.85 mg/dl level, with 70.0% sensitivity, 57.1% specificity, 41.2% PPV and 81.6% NPV. At a 1.83 ratio, DDFR might also identify ischemic stroke with 80.0% sensitivity, 67.1% specificity, 51.1% PPV, and 88.7% NPV.

Conclusion

We showed D-dimer, fibrinogen, and DDFR as promising, affordable, and non-invasive biomarkers for the detection of ischemic stroke among subjects with hypertension. This will help clinicians make an early diagnosis and better guide patient therapy.

In silico study of combination thrombolytic therapy with alteplase and mutant pro-urokinase for fibrinolysis in ischemic stroke

The synergistic advantage of combining tissue plasminogen activator (tPA) with pro-urokinase (proUK) for thrombolysis has been demonstrated in several in vitro experiments, and a single site proUK mutant (m-proUK) has been developed for better stability in plasma. Based on these studies, combination thrombolytic therapy with intravenous tPA and m-proUK has been suggested as a promising treatment for patients with ischemic stroke. This paper evaluates the efficacy and safety of the dual therapy by computational simulations of pharmacokinetics and pharmacodynamics coupled with a local fibrinolysis model. Seven dose regimens are simulated and compared with the standard intravenous tPA monotherapy. Our simulation results provide more insights into the complementary reaction mechanisms of tPA and m-proUK during clot lysis and demonstrate that the dual therapy can achieve a similar recanalization time (about 50 min) to tPA monotherapy, while keeping the circulating fibrinogen level within a normal range. Specifically, our results show that for all dual therapies with a 5 mg tPA bolus, the plasma concentration of fibrinogen remains stable at around 7.5 μM after a slow depletion over 50 min, whereas a rapid depletion of circulating fibrinogen (to 5 μM) is observed with the standard tPA therapy, indicating the potential advantage of dual therapy in reducing the risk of intracranial hemorrhage. Through simulations of varying dose combinations, it has been found that increasing tPA bolus can significantly affect fibrinogen level but only moderately improves recanalization time. Conversely, m-proUK doses and infusion duration exhibit a mild impact on fibrinogen level but significantly affect recanalization time. Therefore, future optimization of dose regimen should focus on limiting the tPA bolus while adjusting m-proUK dosage and infusion rate. Such adjustments could potentially maximize the therapeutic advantages of this combination therapy for ischemic stroke treatment.

Unlocking the Medicinal Mysteries: Preventing Lacunar Stroke with Drug Repurposing

Currently, only the general control of the risk factors is known to prevent lacunar cerebral infarction, but it is unknown which type of medication for controlling the risk factors has a causal relationship with reducing the risk of lacunar infarction. To unlock this medical mystery, drug-target Mendelian randomization analysis was applied to estimate the effect of common antihypertensive agents, hypolipidemic agents, and hypoglycemic agents on lacunar stroke. Lacunar stroke data for the transethnic analysis were derived from meta-analyses comprising 7338 cases and 254,798 controls. We have confirmed that genetic variants mimicking calcium channel blockers were found to most stably prevent lacunar stroke. The genetic variants at or near HMGCR, NPC1L1, and APOC3 were predicted to decrease lacunar stroke incidence in drug-target MR analysis. These variants mimic the effects of statins, ezetimibe, and antisense anti-apoC3 agents, respectively. Genetically proxied GLP1R agonism had a marginal effect on lacunar stroke, while a genetically proxied improvement in overall glycemic control was associated with reduced lacunar stroke risk. Here, we show that certain categories of drugs currently used in clinical practice can more effectively reduce the risk of stroke. Repurposing several drugs with well-established safety and low costs for lacunar stroke prevention should be given high priority when doctors are making decisions in clinical practice. This may contribute to healthier brain aging.

Thrombus composition and thrombolysis resistance in stroke

A State of the Art lecture titled "Thrombus Composition and Thrombolysis Resistance in Stroke" was presented at the ISTH Congress in 2022. Intravenous thrombolysis (IVT) remains the only pharmacologic option to re-establish cerebral perfusion at the acute phase of ischemic stroke. IVT is based on the administration of recombinant tissue plasminogen activator with the objective of dissolving fibrin, the major fibrillar protein component of thrombi. Almost 30 years on from its introduction, although the clinical benefits of IVT have been clearly demonstrated, IVT still suffers from a relatively low efficacy, with a rate of successful early recanalization below 50% overall. Analyses of thrombectomy-recovered acute ischemic stroke (AIS) thrombi have shown that apart from occlusion site, thrombus length, and collateral status, AIS thrombus structure and composition are also important modulators of IVT efficacy. In this article, after a brief presentation of IVT principle and current knowledge on IVT resistance, we review recent findings on how compaction and structural alterations of fibrin together with nonfibrin thrombus components such as neutrophil extracellular traps and von Willebrand factor interfere with IVT in AIS. We further discuss how these new insights could soon result in the development of original adjuvant therapies for improved IVT in AIS. Finally, we summarize relevant new data presented during the 2022 ISTH Congress.

Fibrinogen as a Predictor of Early Neurological Deterioration in Acute Ischemic Stroke - Evidence From the Indian Population

Background

Early neurological deterioration (END) is a common occurrence in ischemic stroke and contributes significantly to poor outcomes. Although multiple factors that predict END have already been identified, the role of fibrinogen - a key component of the coagulation pathway, is controversial.

Objective

To assess the role of fibrinogen in predicting END and poor hospital outcome in patients with acute ischemic stroke.

Design

Single-centre prospective observational study.

Methods

141 patients with acute ischemic stroke were analyzed in this prospective observational study from a single tertiary-care hospital in East India. END was defined as a worsening of ≥2 points on the National Institutes of Health Stroke Scale (NIHSS) within 7 days of admission. A score of 3-5 on the Modified Rankin Scale (mRS), a stroke recurrence event or death during hospital stay was considered poor hospital outcome. We performed univariate analysis using age, sex, body-mass index (BMI), hypertension, diabetes, NIHSS scores, stroke etiology, blood glucose and lipid parameters and plasma fibrinogen to develop a logistic regression model to establish the independent predictors of END and poor outcome.

Results

Age (Odds Ratio (OR) 1.034 [95% CI 1.001-1.069], P = .046), NIHSS score at admission (OR 1.152 [95% CI 1.070-1.240], P < .001) and fibrinogen (OR 1.011 [95%CI 1.006-1.015], P < .001) were independent predictors of END in patients with acute ischemic stroke. Factors independently associated with poor outcome were NIHSS score at admission (OR 1.257 [95% CI 1.150-1.357], P < .001), fasting plasma glucose (OR 1.007 [95% CI 1.001-1.013], P = .020), and fibrinogen [OR 1.004 [95% CI 1.000-1.007], P = .038).

Conclusion

The significant role of fibrinogen in determining neurological worsening and subsequent poor outcomes in patients with acute ischemic stroke may help in early prognostication and guided therapeutic interventions.

Role of plaque inflammation in symptomatic carotid stenosis

Objective

Prior studies have shown that plaque inflammation on FDG-PET and the symptomatic carotid atheroma inflammation lumen-stenosis (SCAIL) score were associated with recurrent ischemic events, but the findings have thus far not been widely validated. Therefore, we aimed to validate the findings of prior studies.

Methods

A single-center prospective cohort study that recruited patients with (1) recent TIA or ischemic stroke within the past 30 days, (2) ipsilateral carotid artery stenosis of ≥50%, and (3) were not considered for early carotid revascularization. The (1) maximum standardized uptake value (SUVmax) of the symptomatic carotid plaque, (2) the SCAIL score, and (3) stenosis severity of the symptomatic carotid artery were measured for all patients. The outcomes were (1) a 90-day ipsilateral ischemic stroke and (2) a 90-day ipsilateral symptomatic TIA or major adverse cardiovascular event (MACE).

Results

Among the 131 patients included in the study, the commonest cardiovascular risk factor was hypertension (95 patients, 72.5%), followed by diabetes mellitus (77 patients, 58.8%) and being a current smoker (64 patients, 48.9%). The median (IQR) duration between the index cerebral ischemic event and recruitment to the study was 1 (0, 2.5) days. The median (IQR) duration between the index cerebral ischemic event and FDG-PET was 5 (4, 7) days. A total of 14 (10.7%) patients had a 90-day stroke, and 41 (31.3%) patients had a 90-day TIA or MACE. On comparison of the predictive performances of the SCAIL score and SUVmax, SUVmax was found to be superior to the SCAIL score for predicting both 90-day ipsilateral ischemic stroke (AUC: SCAIL = 0.79, SUVmax = 0.92; p < 0.001; 95% CI = 0.072, 0.229) and 90-day TIA or MACE (AUC: SCAIL = 0.76, SUVmax = 0.84; p = 0.009; 95% CI = 0.020, 0.143).

Conclusion

Plaque inflammation as quantified on FDG-PET may serve as a reliable biomarker for risk stratification among patients with ECAD and recent TIA or ischemic stroke. Future studies should evaluate whether patients with significant plaque inflammation as quantified on FDG-PET benefit from carotid revascularization and/or anti-inflammatory therapy.

Biomarkers for Transient Ischemic Attack: A Brief Perspective of Current Reports and Future Horizons

Cerebrovascular disease is the leading cause of long-term disability in the world and the third-leading cause of death in the United States. The early diagnosis of transient ischemic attack (TIA) is of great importance for reducing the mortality and morbidity of cerebrovascular diseases. Patients with TIA have a high risk of early subsequent ischemic stroke and the development of permanent nervous system lesions. The diagnosis of TIA remains a clinical diagnosis that highly relies on the patient's medical history assessment. There is a growing list of biomarkers associated with different components of the ischemic cascade in the brain. In this review, we take a closer look at the biomarkers of TIA and their validity with a focus on the more clinically important ones using recent evidence of their reliability for practical usage.

Impact of Helicobacter pylori-Related Metabolic Syndrome Parameters on Arterial Hypertension

Arterial hypertension is a risk factor for several pathologies, mainly including cardio-cerebrovascular diseases, which rank as leading causes of morbidity and mortality worldwide. Arterial hypertension also constitutes a fundamental component of the metabolic syndrome. Helicobacter pylori infection is one of the most common types of chronic infection globally and displays a plethora of both gastric and extragastric effects. Among other entities, Helicobacter pylori has been implicated in the pathogenesis of the metabolic syndrome. Within this review, we illustrate the current state-of-the-art evidence, which may link several components of the Helicobacter pylori-related metabolic syndrome, including non-alcoholic fatty liver disease and arterial hypertension. In particular, current knowledge of how Helicobacter pylori exerts its virulence through dietary, inflammatory and metabolic pathways will be discussed. Although there is still no causative link between these entities, the emerging evidence from both basic and clinical research supports the proposal that several components of the Helicobacter pylori infection-related metabolic syndrome present an important risk factor in the development of arterial hypertension. The triad of Helicobacter pylori infection, the metabolic syndrome, and hypertension represents a crucial worldwide health problem on a pandemic scale with high morbidity and mortality, like COVID-19, thereby requiring awareness and appropriate management on a global scale.

Baseline or 90-day fibrinogen levels and long-term outcomes after ischemic stroke or TIA: Results from the China national stroke registry Ⅲ

BACKGROUND AND AIMS

Elevated fibrinogen levels have been observed in patients with acute ischemic stroke, but the association of fibrinogen with stroke outcomes is still undefined. We aimed to assess the association between baseline or 90-day fibrinogen levels and long-term outcomes in patients with ischemic stroke or transient ischemic attack (TIA).

METHODS

Using data from the China National Stroke Registry Ⅲ, this substudy included 10 518 patients within 7 days (baseline) of onset and 6268 patients at 90 days of recovery. Multivariate Cox regression and logistic regression analyses were used to assess the associations of fibrinogen with poor functional outcome (modified Rankin Scale score 3-6), dependence (modified Rankin Scale score 3-5), all-cause death, and stroke recurrence at 1 year.

RESULTS

Fibrinogen levels at 90 days were higher than those at baseline (443.5 mg/dl versus 393.7 mg/dl; p < 0.001). A high baseline fibrinogen level was associated with poor functional outcome (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.35-1.97) and dependence (OR, 1.68; 95% CI, 1.36-2.09) after adjusting for all confounding risk factors. In contrast, further adjustment for high-sensitivity C-reactive protein attenuated the association between baseline fibrinogen level and all-cause death or stroke recurrence. Furthermore, a high 90-day fibrinogen level was also associated with poor functional outcome (OR, 1.46; 95% CI, 1.07-2.00) and dependence (OR, 1.43; 95% CI, 1.03-1.98) after adjusting for all confounding risk factors.

CONCLUSIONS

High baseline and 90-day fibrinogen levels were associated with outcomes in patients with ischemic stroke or TIA.

Scalable Bio Marker Combinations for Early Stroke Diagnosis: A Systematic Review

Background: Acute stroke treatment is a time-critical process in which every minute counts. Laboratory biomarkers are needed to aid clinical decisions in the diagnosis. Although imaging is critical for this process, these biomarkers may provide additional information to distinguish actual stroke from its mimics and monitor patient condition and the effect of potential neuroprotective strategies. For such biomarkers to be effectively scalable to public health in any economic setting, these must be cost-effective and non-invasive. We hypothesized that blood-based combinations (panels) of proteins might be the key to this approach and explored this possibility through a systematic review. Methods: We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines for systematic review. Initially, the broader search for biomarkers for early stroke diagnosis yielded 704 hits, and five were added manually. We then narrowed the search to combinations (panels) of the protein markers obtained from the blood. Results: Twelve articles dealing with blood-based panels of protein biomarkers for stroke were included in the systematic review. We observed that NR2 peptide (antibody against the NR2 fragment) and glial fibrillary acidic protein (GFAP) are brain-specific markers related to stroke. Von Willebrand factor (vWF), matrix metalloproteinase 9 (MMP-9), and S100β have been widely used as biomarkers, whereas others such as the ischemia-modified albumin (IMA) index, antithrombin III (AT-III), and fibrinogen have not been evaluated in combination. We herein propose the following new combination of biomarkers for future validation: panel 1 (NR2 + GFAP + MMP-9 + vWF + S100β), panel 2 (NR2 + GFAP + MMP-9 + vWF + IMA index), and panel 3 (NR2 + GFAP + AT-III + fibrinogen). Conclusions: More research is needed to validate, identify, and introduce these panels of biomarkers into medical practice for stroke recurrence and diagnosis in a scalable manner. The evidence indicates that the most promising approach is to combine different blood-based proteins to provide diagnostic precision for health interventions. Through our systematic review, we suggest three novel biomarker panels based on the results in the literature and an interpretation based on stroke pathophysiology.

Quantitatively monitoring acute ischemic stroke patients post recombinant tissue plasminogen activator treatment

BACKGROUND AND AIMS

Thrombolytic therapy is widely used to treat acute ischemic stroke (AIS) patients. As intracerebral hemorrhage is a life-threatening complication of this therapy, monitoring the fibrinolytic and coagulation systems is imperative. However, existing studies on plasmin inhibitor complex (PIC) and thrombin-antithrombin III complex (TAT) mostly apply the enzyme-linked immunosorbent assay (ELISA) method. The aim of this study is to establish the baseline of thrombolytic treatment for AIS patients; to monitor the fibrinolytic and coagulation system following alteplase administration; to ascertain the proper time point to predict intracerebral hemorrhage.

METHODS

The method used to assess a patient's intravascular situation, namely chemiluminescence, was used to quantitatively assess the PIC, TAT, and thrombomodulin (TM). Immuno-turbidimetric was used to assess the concentration of D-dimer, fibrin/fibrinogen degradation products (FDP), and the Von Willebrand factor (vWF). The Clauss clotting method was used to assay the activated partial thromboplastin time (APTT), prothrombin time (PT) and FIB.

RESULTS

PIC increased to its peak concentration at 3 hours post intravenous (IV) alteplase infusion and decreased by nearly 50% every 3 hours thereafter. After 24 hours, PIC returned to its normal range, while D-dimer and FDP decreased 3 hours later compared to PIC. PT and APTT exhibited no obvious change during the 24-hour period. TM also exhibited no changes during the treatment.

CONCLUSION

PIC decreased 3 hours earlier than D-dimer and FDP. The combined test of PIC, D-dimer, and fibrinogen can be used to monitor the fibrinolytic system after the IV alteplase infusion. The use of IV alteplase had no impact on the endothelium. Creating a patient's individual data curve could assist in the prediction of hemorrhagic transformation (HT) and a stroke occurring.

Interleukin-6, C-reactive protein, fibrinogen, and risk of recurrence after ischaemic stroke: Systematic review and meta-analysis

BACKGROUND

Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification.

METHODS

We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures.

RESULTS

Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in loge-CRP (1.14, 95% CI 1.06-1.22, p < 0.01)] and MVEs (pooled HR 1.21, CI 1.10-1.34, p < 0.01). Fibrinogen was also associated with recurrent stroke (HR 1.26, CI 1.07-1.47, p < 0.01) and MVEs (HR 1.31, 95% CI 1.15-1.49, p < 0.01). Trends were identified for IL-6 for recurrent stroke (HR per 1-SD increase 1.17, CI 0.97-1.41, p = 0.10) and MVEs (HR 1.22, CI 0.96-1.55, p = 0.10).

CONCLUSION

Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.

Risk Factors of Vitamin D Deficiency in Chinese Ischemic Stroke Patients: A Cross-Sectional Study

Purpose

Lower serum vitamin D has been reported to be associated with stroke. This study aimed to analyze the risk factors of vitamin deficiency in Chinese stroke patients, and further analyze its impact in different gender and their clinical variables.

Methods

982 stroke patients were enrolled. Laboratory parameters such as serum vitamin D, apolipoprotein A-I (ApoA-I), apolipoprotein B (ApoB), ApoA-I/ApoB, cholesterol (CH), fibrinogen (FIB), blood glucose (Glu), high-density lipoprotein (HDL), low-density lipoprotein cholesterol (LDL-C), and triglyceride (TG) were collected and recorded. The severity of stroke was assessed by National Institute of Health Stroke Scale (NIHSS) score. Based on their serum vitamin D level, patients were divided into three groups: Vitamin D deficiency (<50 nmol/L), vitamin D insufficiency (≥50–75 nmol/L) and vitamin D sufficiency (≥75 nmol/L) and differences were compared among the three groups. Statistical analyses were done to assess the risk factors for serum vitamin D deficiency in our ischemic stroke patients.

Results

Gender, NIHSS, and FIB showed significant differences among the vitamin D groups (P < 0.001 ∼ P = 0.002). The female gender (OR = 2.422, P < 0.001), severity of stroke using NIHSS (OR = 1.055, P = 0.008) and FIB (OR = 1.256, P = 0.005) were risk factors of vitamin D deficiency in ischemic stroke patients. In subgroup analysis, NIHSS was significantly associated with vitamin D deficiency in the male group (OR = 1.087, P = 0.002) and higher FIB group (OR = 1.078, P = 0.001).

Conclusions

The female gender, severity of stroke using NIHSS and FIB were risk factors for vitamin D deficiency in our incident stroke patients. NIHSS was more sensitive to vitamin D deficiency in male ischemic stroke patients. Besides, under higher FIB circumstance, the increasing NIHSS score was more related to the vitamin D deficiency. Levels of vitamin D in patients with ischemic stroke should be well monitored during the disease cascade.

Value of Combining of the NLR and the Fibrinogen Level for Predicting Stroke-Associated Pneumonia

PURPOSE

To evaluate the value of the NLR (neutrophil-to-lymphocyte ratio) and the fibrinogen level in predicting stroke-associated pneumonia (SAP) in acute ischemic stroke (AIS) patients.

PATIENTS AND METHODS

In total, we enrolled 734 medical-ward patients with AIS in this retrospective study. Patients were divided into SAP (n=52) and non-SAP (n=682) groups according to the diagnostic criteria of SAP. Binary logistic regression analysis was used to analyze the relationship between the NLR, serum fibrinogen concentration and SAP. Receiver operating characteristic (ROC) curves were generated to identify the optimal cutoff points and assess the diagnostic value of the NLR, serum fibrinogen and the combination of NLR and fibrinogen in predicting SAP.

RESULTS

SAP occurred in 52 (7.08%) patients among the enrolled AIS patients. Binary logistic regression analysis showed that the NLR (odds ratio [OR]: 2.802, 95% confidence interval [CI]: 1.302-6.032, P=0.008) and serum fibrinogen concentration (OR: 7.850, 95% CI: 3.636-16.949, P=0.000) were independently associated with a higher risk of SAP incidence after adjusting for age, sex, ASPECT score, atrial fibrillation, nasogastric tube feeding, LDL-C and TC, temperature at admission and mechanical ventilation. The optimal cutoff points of the NLR and serum fibrinogen to distinguish SAP among AIS patients were 3.603 (AUC, 0.690; NPV, 95.78; PPV, 19.01) and 4.595 (AUC, 0.727; NPV, 95.60; PPV, 24.49), respectively. When the combination of NLR and fibrinogen was used to predict SAP, the optimal cutoff points were >2.436 for NLR and >3.24 for fibrinogen (AUC, 0.758; NPV, 98.50; PPV, 11.80).

CONCLUSION

The NLR and serum fibrinogen might have greater negative diagnostic value in predicting SAP among AIS patients. Combining the NLR and serum fibrinogen showed an increased AUC for predicting SAP among AIS patients.

Large-vessel thrombotic stroke despite concurrent therapeutic anticoagulation in COVID-19-positive patient

The current COVID-19 pandemic caused by the novel SARS-CoV-2 virus is now recognized to be associated with a coagulopathy that can result in arterial and venous thromboses. In this report, we describe a case of large-vessel cerebrovascular thrombus in a therapeutically anticoagulated 89-year-old male admitted with COVID-19 infection. Despite clinical improvement following COVID-19 pneumonitis, symptoms of an acute left-sided total anterior circulation stroke rapidly developed 10 days after initial COVID-19 symptom onset. Computed tomography angiography imaging confirmed acute large-vessel thrombus in the terminal segment of the internal carotid artery resulting in acute right middle cerebral artery territory infarction. Thromboembolic events in the context of COVID-19 infection have recently been described in critically unwell patients. However, to the best of our knowledge, this is one of the first cases of large-vessel thrombus in a patient with COVID-19 infection receiving concurrent therapeutic anticoagulation.

Pathophysiology, Mechanism, and Outcome of Ischemic Stroke in Cancer Patients

OBJECTIVES

The purpose of this study is to assess the risk factors, biomarkers of stroke, mechanism, and outcomes of cerebral infarction among cancerous diseases.

MATERIALS & METHODS

156 patients presented by acute ischemic stroke were divided into two groups: the first group included 78 ischemic stroke patients associated with different types of cancer and the second group (control group) included 78 ischemic stroke patients not associated with cancer. Both groups were compared regarding the risk factors, previous thrombotic activity, subtypes, biomarkers of stroke, and outcomes.

RESULTS

Cancer patients presented by acute ischemic stroke were accompanied by a significantly less incidence of diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease, and atrial fibrillation than non-cancer patients (P < 0.001). While, levels of biomarkers of inflammation like erythrocyte sedimentation rate and C-reactive protein, and stroke biomarkers like fibrinogen, and D-dimer, all together were highly elevated in cancerous disease group of patients (P < 0.01). The prevalence of deep vein thrombosis, pulmonary embolism, and myocardial infarction was significantly higher in patients with cancer than in control patients without cancer (P = 0.008, P < 0.01 and P < 0.01 respectively). The most common stroke etiologies were atherosclerosis of large arteries and stroke of undetermined cause in a cancerous group of patients. Cancer patients were accompanied by significant higher mortality rate (P = 0.005), and more disability as determined by mRS (P < 0.005) CONCLUSIONS: Pathophysiology and mechanism of ischemic stroke in cancerous disease patients were due to different risk factors, biomarkers of stroke, and subtypes in comparison with non- cancerous cases.

Elevated plasma fibrinogen indicates short-term poor outcome in patients with acute ischemic stroke after intravenous thrombolysis

BACKGROUND

Fibrinogen is a central protein of hemostasis and a major determinant of plasma viscosity and key factor for platelet activation. The aim of this study is to investigate the relationship between fibrinogen level and short-term outcome in acute ischemic stroke patients receiving intravenous thrombolysis.

METHODS

This retrospective study included 176 acute ischemic stroke patients who received intravenous thrombolysis with recombinant tissue plasminogen activator and provided plasma fibrinogen level within 24 h after stroke onset. Patients were categorized by plasma fibrinogen level: Quartile 1 (≤ 1.74 g/L), Quartile 2 (1.75-2.08 g/L), Quartile 3 (2.09-2.69 g/L), and Quartile 4 (> 2.69 g/L). The medical record of each patient was reviewed, and demographic, clinical and laboratory information was abstracted. Functional outcome at 14 days was assessed with the modified Rankin Scale.

RESULTS

Poor outcome was present in 75 (42.6%) of the 176 patients that were included in the study (mean age, 72 years; male, 53.4%). After adjustment for potential confounding variables, higher plasma fibrinogen level on admission was associated with poor outcome (adjusted odds ratio 10.45, 95% confidence interval 1.49-73.15 for Q4:Q1; P = 0.02). According to receiver operating characteristic analysis, the best discriminating factor for poor outcome was a plasma fibrinogen level ≥ 2.585 g/L (area under the curve 0.672; sensitivity 50.7%; specificity 86.1%).

CONCLUSION

Elevated plasma fibrinogen levels on admission are significantly associated with poor outcome after admission for acute ischemic stroke, suggesting the potential role of plasma fibrinogen level as a predictive marker for short-term poor outcome in acute ischemic stroke patients receiving thrombolytic therapy.

Cohort profile: BIOVASC-late, a prospective multicentred study of imaging and blood biomarkers of carotid plaque inflammation and risk of late vascular recurrence after non-severe stroke in Ireland

PURPOSE

Inflammation is important in stroke. Anti-inflammatory therapy reduces vascular events in coronary patients. ¹⁸F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) identifies plaque inflammation-related metabolism. However, long-term prospective cohort studies investigating the association between carotid plaque inflammation, identified on ¹⁸F-FDG PET and the risk of recurrent vascular events, have not yet been undertaken in patients with stroke.

PARTICIPANTS

The Biomarkers Imaging Vulnerable Atherosclerosis in Symptomatic Carotid disease (BIOVASC) study and Dublin Carotid Atherosclerosis Study (DUCASS) are two prospective multicentred observational cohort studies, employing near-identical methodologies, which recruited 285 patients between 2008 and 2016 with non-severe stroke/transient ischaemic attack and ipsilateral carotid stenosis (50%-99%). Patients underwent coregistered carotid ¹⁸F-FDG PET/CT angiography and phlebotomy for measurement of inflammatory cytokines. Plaque ¹⁸F-FDG-uptake is expressed as maximum standardised uptake value (SUV_max) and tissue-to-background ratio. The BIOVASC-Late study is a follow-up study (median 7 years) of patients recruited to the DUCASS/BIOVASC cohorts.

FINDINGS TO DATE

We have reported that ¹⁸F-FDG-uptake in atherosclerotic plaques of patients with symptomatic carotid stenosis predicts early recurrent stroke, independent of luminal narrowing. The incorporation of ¹⁸F-FDG plaque uptake into a clinical prediction model also improves discrimination of early recurrent stroke, when compared with risk stratification by luminal stenosis alone. However, the relationship between ¹⁸F-FDG-uptake and late vascular events has not been investigated to date.

FUTURE PLANS

The primary aim of BIOVASC-Late is to investigate the association between SUV_max in symptomatic 'culprit' carotid plaque (as a marker of systemic inflammatory atherosclerosis) and the composite outcome of any late major vascular event (recurrent ischaemic stroke, coronary event or vascular death). Secondary aims are to investigate associations between: (1) SUV_max in symptomatic plaque, and individual vascular endpoints (2) SUV_max in asymptomatic contralateral carotid plaque and SUV_max in ipsilateral symptomatic plaque (3) SUV_max in asymptomatic carotid plaque and major vascular events (4) inflammatory cytokines and vascular events.

Fibrinogen and risk of dementia: A systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis is to evaluate the association of fibrinogen with risk of dementia and its subtypes.

METHODS

Embase, Pubmed and Web of Science were retrieved systematically up to February 2019. Standard mean difference (SMD) with 95 % confidence intervals was estimated using random-effects models.

RESULTS

Sixteen studies involving 3,649 participants were summarized. Patients with all-cause dementia exhibited higher fibrinogen levels than those in non-dementia controls (SMD = 0.90 [0.43;1.36] p < 0.01). Further subgroup analysis revealed a positive association of fibrinogen with vascular dementia (VaD) (SMD = 1.11 [0.45;1.78] p < 0.01) rather than Alzheimer's disease (AD) (SMD = 0.01 [-0.17;0.19]) p = 0.92) and Parkinson's disease dementia (PDD) (SMD = 0.35 [-0.23;0.93] p = 0.24). This correlation was significant in Europeans (SMD = 0.92 [0.34;1.49] p < 0.01), but probably not in Asian based populations (SMD = 1.04 [-0.09;2.17] p = 0.07), and gradually declined with advancing age (60 ≤ age < 70: SMD = 1.22 [0.38;2.06] p < 0.01; 70 ≤ age < 80: SMD = 0.29 [0.04;0.53] p = 0.02; age ≥ 80: SMD = 0.01 [-0.12;0.15] p = 0.84).

CONCLUSIONS

Plasma fibrinogen is a potential risk factor for all-cause dementia and VaD under the age of 80, and is more obvious in cohorts with people of European descent.

Long-term risk of stroke and its predictors in transient ischaemic attack patients in Germany

BACKGROUND AND PURPOSE

Little is known about the long-term association between transient ischaemic attack (TIA) and stroke. Therefore, the goal of this study was to analyze the long-term risk of stroke and associated predictors in a large cohort of TIA patients followed in general practices in Germany.

METHODS

This study included patients with an initial TIA diagnosis and subsequently followed up in one of 1262 general practices in Germany between January 2007 and December 2016 (N = 19 824 patients). The primary outcome of the study was the risk of ischaemic stroke within 10 years of the initial diagnosis of TIA. The secondary outcome was the identification of demographic, clinical and pharmaceutical variables significantly associated with stroke in TIA patients.

RESULTS

Within 10 years of the initial TIA diagnosis, 18.3% of individuals were diagnosed with stroke. Age was positively associated with stroke, with hazard ratios ranging from 1.88 in patients aged 51-60 years to 4.00 in those aged >80 years (reference group: patients aged ≤50 years). Furthermore, male sex, hypertension, diabetes mellitus, atrial fibrillation and ischaemic heart diseases had an additional impact on the risk of stroke. Finally, new oral anticoagulants, heparins, diuretics, angiotensin II receptor blockers and platelet aggregation inhibitors were identified as protective factors.

CONCLUSIONS

In a cohort of almost 20 000 TIA patients, 18.3% were diagnosed with stroke within 10 years after the TIA index event. Several demographic, clinical and pharmaceutical variables significantly predicted the long-term risk of stroke in TIA patients.

Emerging Biomarkers in Vascular Cognitive Impairment and Dementia: From Pathophysiological Pathways to Clinical Application

Vascular pathology is the second most common neuropathology of dementia after Alzheimer’s disease (AD), with small vessels disease (SVD) being considered the major cause of vascular cognitive impairment and dementia (VCID). This review aims to evaluate pathophysiological pathways underlying a diagnosis of VCID. Firstly, we will discuss the role of endothelial dysfunction, blood-brain barrier disruption and neuroinflammation in its pathogenesis. Then, we will analyse different biomarkers including the ones of inflammatory responses to central nervous system tissue injuries, of coagulation and thrombosis and of circulating microRNA. Evidences on peripheral biomarkers for VCID are still poor and large-scale, prospectively designed studies are needed to translate these findings into clinical practice, in order to set different combinations of biomarkers to use for differential diagnosis among types of dementia.

The Impact of Physical Activity Before and After Stroke on Stroke Risk and Recovery: a Narrative Review

PURPOSE OF THE REVIEW

Summarising the evidence for pre- and post-stroke physical activity (PA) and exercise to reduce stroke risk, and improve recovery and brain health.

RECENT FINDINGS

Pre-stroke PA reduces the risk of stroke, and post-stroke PA and exercise reduce cardiovascular risk factors, which can moderate the risk of recurrent strokes. Pre-clinical evidence indicates that exercise enhances neuroplasticity. The results from clinical studies showed that exercise changes brain activity patterns in stroke survivors, which can be a signal neuroplasticity. The intensity of pre- and post-stroke PA and exercise is a key factor with higher intensities leading to greater benefits, including improvement in fitness. Having low fitness levels is an independent predictor for increased risk of stroke. Higher intensity leads to greater benefits; however, the optimum intensity of PA and exercise is yet unknown and needs to be further investigated. Strategies to decrease sedentary behaviour and improve fitness need to be considered.

Season and myocardial injury in patients with ST-segment elevation myocardial infarction: A cardiac magnetic resonance imaging study

Background

Little is known about the causality and pathological mechanism underlying the association of seasonal variation with myocardial injury in patients with ST-segment elevation myocardial infarction (STEMI).

Objective

We evaluated the association of seasonal effect with myocardial injury using cardiovascular magnetic resonance (CMR) imaging in STEMI patients undergoing primary percutaneous coronary intervention (PCI).

Methods

In 279 patients undergoing primary PCI for STEMI, CMR was performed for a median of 3.3 days after the index procedure. Of these, STEMI occurred in 56 patients in the winter (Winter group), 80 patients in the spring (Spring group), 76 patients in the summer (Summer group), and 67 patients in the autumn (Autumn group), respectively. We compared myocardial infarct size, extent of area at risk (AAR), myocardial salvage index (MSI) and microvascular obstruction (MVO) area as assessed by CMR according to the season in which STEMI occurred.

Results

In the CMR analysis, the myocardial infarct size was not significantly different among the Winter group (21.0 ± 10.5%), the Spring group (19.6 ± 11.5%), the Summer group (18.6 ± 10.6%), and the Autumn group (21.1 ± 11.3%) (P = 0.475). The extent of AAR, MSI, and MVO areas were similar among the four groups. In the subgroup analysis, myocardial infarct size, extent of AAR, MSI, and MVO were not significantly different between the Harsh climate (winter + summer) and the Mild climate (spring + autumn) groups.

Conclusions

Seasonal influences may not affect advanced myocardial injury in STEMI patients undergoing primary PCI.

Mendelian randomization evaluation of causal effects of fibrinogen on incident coronary heart disease

BACKGROUND

Fibrinogen is an essential hemostatic factor and cardiovascular disease risk factor. Early attempts at evaluating the causal effect of fibrinogen on coronary heart disease (CHD) and myocardial infraction (MI) using Mendelian randomization (MR) used single variant approaches, and did not take advantage of recent genome-wide association studies (GWAS) or multi-variant, pleiotropy robust MR methodologies.

METHODS AND FINDINGS

We evaluated evidence for a causal effect of fibrinogen on both CHD and MI using MR. We used both an allele score approach and pleiotropy robust MR models. The allele score was composed of 38 fibrinogen-associated variants from recent GWAS. Initial analyses using the allele score used a meta-analysis of 11 European-ancestry prospective cohorts, free of CHD and MI at baseline, to examine incidence CHD and MI. We also applied 2 sample MR methods with data from a prevalent CHD and MI GWAS. Results are given in terms of the hazard ratio (HR) or odds ratio (OR), depending on the study design, and associated 95% confidence interval (CI). In single variant analyses no causal effect of fibrinogen on CHD or MI was observed. In multi-variant analyses using incidence CHD cases and the allele score approach, the estimated causal effect (HR) of a 1 g/L higher fibrinogen concentration was 1.62 (CI = 1.12, 2.36) when using incident cases and the allele score approach. In 2 sample MR analyses that accounted for pleiotropy, the causal estimate (OR) was reduced to 1.18 (CI = 0.98, 1.42) and 1.09 (CI = 0.89, 1.33) in the 2 most precise (smallest CI) models, out of 4 models evaluated. In the 2 sample MR analyses for MI, there was only very weak evidence of a causal effect in only 1 out of 4 models.

CONCLUSIONS

A small causal effect of fibrinogen on CHD is observed using multi-variant MR approaches which account for pleiotropy, but not single variant MR approaches. Taken together, results indicate that even with large sample sizes and multi-variant approaches MR analyses still cannot exclude the null when estimating the causal effect of fibrinogen on CHD, but that any potential causal effect is likely to be much smaller than observed in epidemiological studies.

Fibrinogen concentrations predict long-term cognitive outcome in young ischemic stroke patients

BACKGROUND

Cognitive impairment is frequent after stroke, and young patients may live with this consequence for a long time. Predictors of cognitive outcomes after stroke represent a current gap of knowledge.

OBJECTIVES

To investigate levels of three hemostatic biomarkers as predictors of long-term cognitive function after stroke.

METHODS

This longitudinal study included consecutively recruited patients with ischemic stroke at 18-69 years (n = 268). Blood was collected 3 months after index stroke and analyzed for plasma concentrations of fibrinogen, von Willebrand factor (VWF) and tissue-type plasminogen activator (t-PA) antigen. Cognitive function 7 years after index stroke was assessed by the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS). Participants with stroke <50 years of age were also examined by the Trail Making Test A and B (n = 41). Associations between biomarker concentrations and cognitive scales were assessed in the whole group and in participants with stroke <50 years of age.

RESULTS

The hemostatic biomarkers fibrinogen, VWF and t-PA, were all correlated to total BNIS score, but these associations did not withstand adjustment for confounding factors in the whole group. However, in patients <50 years, we found an independent association between fibrinogen concentrations and total BNIS score (βstd = -.27, 95% confidence interval [CI], -0.47 to -0.07) and to performance on the Trail Making Test A (βstd = .31, 95% CI, 0.03-0.58). No such association was seen for the Trail Making Test B.

CONCLUSION

High convalescent fibrinogen concentrations were associated with worse long-term cognitive outcomes in ischemic stroke <50 years of age. We propose further investigations of fibrinogen in relation to cognitive function in stroke in the young.

Risk Factors, Biomarkers, Etiology, Outcome and Prognosis of Ischemic Stroke in Cancer Patients

Introduction: Cerebrovascular disease is the second most common complication in individuals with tumours. The aim of this study was to investigate risk factors, biomarkers, etiology and prognosis of ischemic stroke in cancer patients (ISCPs). Methods: The medical records of 619 consecutive patients who were admitted with acute ischemic stroke from January 2012 to November 2014 were retrospectively evaluated. The patients were divided into two groups (group 1, patients with an active cancer prior to the onset of ischemic stroke; group 2, patients without an active cancer history). The demographic data, risk factors, NIHSS scores, thrombocyte count, D-dimer, fibrinogen and C reactive protein (CRP) level at admission, modified Rankin Scale (mRS) scores in the follow-up period and location of lesions on DWI were recorded. The Mann-Whitney U test, chi-squared test and logistic regression was used for analyzing data, p<0.05 being considered statistically significant. Results: A total of 46 (7.4%) ISCPs were included. Hyperlipidemia was significantly lower in the ISCP group (p=0.001). Elevated thrombocyte counts, D-dimer, fibrinogen and CRP levels at admission, acute multiple ischemic lesions, other causes, mortality in hospital and worse outcome were significantly related to ISCP (p<0.05). On logistic regression analysis, follow up mRS>3, acute multiple ischemic lesions located in more than one vascular territory (AMIMCT) and other causes were significantly associated with ISCP (p<0.001). Conclusion: In our study, other causes, AMIMCT and mRS>3 were more common in the ISCP group. We consider that CCS could be more suitable for detecting other causes than TOAST. Biomarkers could be important in the ISCP group.

Raised Fibrinogen Levels and Outcome in Outpatients With Peripheral Artery Disease

The influence of raised fibrinogen levels on outcome in stable outpatients with peripheral arterial disease (PAD) has not been consistently investigated. We used data from the Factores de Riesgo y ENfermedad Arterial (FRENA) registry to compare ischemic events, major bleeding, and mortality in stable outpatients with PAD, according to their baseline plasma fibrinogen levels. Of 1363 outpatients with PAD recruited in FRENA, 558 (41%) had fibrinogen levels >450 mg/100 mL. Over 18 months, 43 patients presented with acute myocardial infarction, 37 had an ischemic stroke, 51 underwent limb amputation, 19 had major bleeding, and 90 died. Compared to patients with normal levels, those with raised fibrinogen levels had an over 2-fold higher rate of ischemic stroke (rate ratio [RR]: 2.30; 95% confidence interval [CI]: 1.19-4.59), limb amputation (RR: 2.58; 95% CI: 1.46-4.67), or death (RR: 2.27; 95% CI: 1.49-3.51) and an over 3-fold higher rate of major bleeding (RR: 3.90; 95% CI: 1.45-12.1). On multivariate analysis, patients with raised fibrinogen levels had an increased risk of developing subsequent ischemic events (hazard ratio [HR]: 1.61; 95% CI: 1.11-2.32) and major bleeding (HR: 3.42; 95% CI: 1.22-9.61). Stable outpatients with PAD and raised plasma fibrinogen levels had increased rates of subsequent ischemic events and major bleeding.

Are ankylosing spondylitis, psoriatic arthritis and undifferentiated spondyloarthritis associated with an increased risk of cardiovascular events? A prospective nationwide population-based cohort study

Background

To investigate the risk of first-time acute coronary syndrome (ACS), stroke and venous thromboembolism (VTE) in patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA) and undifferentiated spondyloarthritis (uSpA), compared to each other and to the general population (GP).

Methods

This is a prospective nationwide cohort study. Cohorts with AS (n = 6448), PsA (n = 16,063) and uSpA (n = 5190) patients and a GP (n = 266,435) cohort, were identified 2001–2009 in the Swedish National Patient and Population registers. The follow-up began 1 January 2006, or 6 months after the first registered spondyloarthritis (SpA) diagnosis thereafter, and ended at ACS/stroke/VTE event, death, emigration or 31 December 2012. Crude and age- and sex-standardized incidence rates (SIRs) and hazard ratios (HRs) were calculated for incident ACS, stroke or VTE, respectively.

Results

Standardized to the GP cohort, SIRs for ACS were 4.3, 5.4 and 4.7 events per 1000 person-years at risk in the AS, PsA and uSpA cohort, respectively, compared to 3.2 in the GP cohort. SIRs for stroke were 5.4, 5.9 and 5.7 events per 1000 person-years at risk in the AS, PsA and uSpA cohort compared to 4.7 in the GP cohort. Corresponding SIRs for VTE were 3.6, 3.2 and 3.5 events per 1000 person-years at risk compared to 2.2 in the GP cohort. Age-and sex-adjusted HRs (95% CI) for ACS events were significantly increased in AS (1.54 (1.31–1.82)), PsA (1.76 (1.59–1.95)) and uSpA (1.36 (1.05–1.76)) compared to GP. Age-adjusted HRs for ACS was significantly decreased in female AS patients (0.59 (0.37–0.97)) compared to female PsA patients. Age-and sex-adjusted HRs for stroke events were significantly increased in AS (1.25 (1.06–1.48)) and PsA (1.34 (1.22–1.48)), and nonsignificantly increased in uSpA (1.16 (0.91–1.47)) compared to GP. For VTE the age-and sex-adjusted HRs for AS, PsA and uSpA were equally and significantly increased with about 50% compared to GP.

Conclusions

Patients with AS, PsA and uSpA are at increased risk for ACS and stroke events, which emphasizes the importance of identification of and intervention against cardiovascular risk factors in SpA patients. Increased alertness for VTE is warranted in patients with SpA.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1315-z) contains supplementary material, which is available to authorized users.

Molecular Links and Biomarkers of Stroke, Vascular Dementia, and Alzheimer's Disease

Stroke is a very common neurological disease, and it occurs when the blood supply to part of the brain is interrupted and the subsequent shortage of oxygen and nutrients causes damage to the brain tissue. Stroke is the second leading cause of death and the third leading cause of disability-adjusted life years. The occurrence of stroke increases with age, but anyone at any age can suffer a stroke. Stroke can be broadly classified in two major clinical types: ischemic stroke (IS) and hemorrhagic stroke. Research also revealed that stroke, vascular dementia (VaD), and Alzheimer's disease (AD) increase with a number of modifiable factors, and most strokes can be prevented and/or controlled through pharmacological or surgical interventions and lifestyle changes. The pathophysiology of stroke, VaD, and AD is complex, and recent molecular and postmortem brain studies have revealed that multiple cellular changes have been implicated, including inflammatory responses, microRNA alterations, and marked changes in brain proteins. These molecular and cellular changes provide new information for developing therapeutic strategies for stroke and related vascular disorders treatment. IS is the major risk factor for VaD and AD. This chapter summarizes the (1) links among stroke-VaD-AD; (2) updates the latest developments of research in identifying protein biomarkers in peripheral and central nervous system tissues; and (3) critically evaluates miRNA profile and function in human blood samples, animal, and postmortem brains.

Secondary Prevention of Ischemic Cerebrovascular Disease. What Is the Evidence?

Patients who had a transient ischemic attack or stroke are at increased risk of experiencing recurrent cerebrovascular events. For this reason, secondary prevention of ischemic cerebrovascular disease is essential. Several modifiable, lifestyle-associated risk factors have been implicated, such as physical activity, smoking, and alcohol consumption. Established and emerging vascular risk factors are associated with an increased risk of stroke. Pharmacologic treatment, including the use of antiplatelet, antihypertensive, and lipid-lowering agents, has also been shown to reduce the risk of secondary cerebrovascular events. Surgical intervention, either open or endovascular, may be the preferred therapeutic option in well-defined subsets of patients. It is important to establish specific measures for the early detection and prevention of recurrent cerebrovascular disease. Therefore, further research and greater awareness in this field are needed.

Peripheral biomarkers of stroke: Focus on circulatory microRNAs

Stroke is the second leading cause of death in the world. Stroke occurs when blood flow stops, and that stoppage results in reduced oxygen supply to neurons in the brain. The occurrence of stroke increases with age, but anyone at any age can suffer from stroke. Recent research has implicated multiple cellular changes in stroke patients, including oxidative stress and mitochondrial dysfunction, inflammatory responses, and changes in mRNA and proteins. Recent research has also revealed that stroke is associated with modifiable and non-modifiable risk factors. Stroke can be controlled by modifiable risk factors, including diet, cardiovascular, hypertension, smoking, diabetes, obesity, metabolic syndrome, depression and traumatic brain injury. Stroke is the major risk factor for vascular dementia (VaD) and Alzheimer's disease (AD). The purpose of this article is to review the latest developments in research efforts directed at identifying 1) latest developments in identifying biomarkers in peripheral and central nervous system tissues, 2) changes in microRNAs (miRNAs) in patients with stroke, 3) miRNA profile and function in animal brain, and 4) protein biomarkers in ischemic stroke. This article also reviews research investigating circulatory miRNAs as peripheral biomarkers of stroke.

Haemostatic biomarkers are associated with long-term recurrent vascular events after ischaemic stroke

Ischaemic stroke patients continue to be at risk for recurrent vascular events for many years. Predictors of long-term prognosis are needed. It was the objective of this study to investigate levels of four haemostatic proteins as long-term predictors of recurrent vascular events after ischaemic stroke. We prospectively followed 548 ischaemic stroke patients, 18-69 years, and registered recurrent vascular events. Plasma levels of tissue-type plasminogen activator (t-PA), von Willebrand factor (VWF), fibrinogen and thrombin activatable fibrinolysis inhibitor activation peptide (TAFI-AP) were measured three months after index stroke. Cox regression models were used to assess associations to outcomes for single biomarkers and for a combined biomarker measure. For single biomarkers significantly associated with any of the outcomes, we performed subanalyses stratified for age, sex, diabetes and atherosclerosis. During 5,637 person-years of follow-up, we registered 74 vascular deaths, 90 recurrent strokes and 62 coronary events. Levels of t-PA, VWF and fibrinogen were significantly associated with vascular death and coronary events. After adjustment, the association between t-PA and vascular death remained (HR per 1 SD increase in plasma level 1.27, 95 % CI 1.00-1.61, p=0.047). The combined effect of t-PA, VWF and fibrinogen was associated with coronary events (adjusted HR 1.35, 1.02-1.80, p=0.04). In non-diabetic patients, an association with coronary events was seen for VWF levels (adjusted HR 2.23, 1.45-3.43, p<0.01). In conclusion, plasma levels of haemostatic factors were associated with vascular death and coronary events, but not with recurrent stroke. Our results suggest that the predictive value of biomarkers differ by specific outcome measure and subgroup of patients.

The Relationship between C-Reactive Protein Level and Discharge Outcome in Patients with Acute Ischemic Stroke

Previous studies showed that C-reactive protein (CRP), an inflammatory marker, was associated with stroke severity and long-term outcome. However, the relationship between the acute-phase CRP level and discharge outcome has received little attention. We prospectively studied 301 patients with acute ischemic stroke (over a period of two weeks) from two hospital stroke wards and one rehabilitation department in Henan, China. Patients’ demographic and clinical data were collected and evaluated at admission. Poor discharge outcome was assessed in patients at discharge using the Modified Rankin Scale (MRS > 2). Multivariate logistic regression analysis was performed to determine the risk factors of poor discharge outcome after adjusting for potential confounders. Poor discharge outcome was observed in 78 patients (25.9%). Univariate analyses showed that factors significantly influencing poor discharge outcome were age, residence, recurrent acute ischemic stroke, coronary heart disease, the National Institutes of Health Stroke Scale (NIHSS) score at admission, non-lacunar stroke, time from onset of stroke to admission, CRP, TBIL (total bilirubin), direct bilirubin (DBIL), ALB (albumin), FIB (fibrinogen) and D-dimer (p < 0.05). After adjusting for age, residence, recurrent ischemic stroke, coronary heart disease, NIHSS score at admission, lacunar stroke, time from onset of stroke to admission, CRP, TBIL, DBIL, ALB, FIB and D-dimer, multivariate logistic regression analyses revealed that poor outcome at discharge was associated with recurrent acute ischemic stroke (OR, 2.115; 95% CI, 1.094–4.087), non-lacunar stroke (OR, 2.943; 95% CI, 1.436–6.032), DBIL (OR, 1.795; 95% CI, 1.311–2.458), and CRP (OR, 4.890; 95% CI, 3.063–7.808). In conclusion, the CRP level measured at admission was found to be an independent predictor of poor outcome at discharge. Recurrent acute ischemic stroke, non-lacunar stroke and DBIL were also significantly associated with discharge outcome in acute ischemic stroke.

The relationship between anemia and recurrence of ischemic stroke in patients with Trousseau's syndrome: A retrospective cross-sectional study

OBJECTIVES

The relationship between cancer and thrombosis was first recognized by the French internist Armand Trousseau in 1865. Trousseau's syndrome is a spectrum of symptoms that result from recurrent thromboembolism associated with cancer or malignancy-related hypercoagulability. In this study, we investigated whether demographics, clinical features, or laboratory findings were able to predict recurrent stroke episodes in patients with Trousseau's syndrome.

METHODS

In total, 178 adult patients were enrolled in this retrospective cross-sectional study. All patients had been admitted to the emergency room of our hospital between January 2011 and September 2014 and were diagnosed with acute ischemic stroke. Patients were divided into two groups: patients with malignancy (Trousseau's syndrome), and patients without malignancy.

RESULTS

There were several significant differences between the laboratory results of the two patient groups. For patients with Trousseau's, the hemoglobin levels for those with one stroke was 12.29 ± 1.81, while those in patients who had experienced more than one stroke was 10.94 ± 2.14 (p = 0.004).

CONCLUSIONS

Trousseau's syndrome is a cancer-associated coagulopathy associated with high morbidity and mortality rates. In this study, anemia was associated with increased stroke recurrence in patients with malignancy (Trousseau's syndrome).

Hyperfibrinogenemia predicts long-term risk of death after ischemic stroke

In stroke patients higher levels of plasma fibrinogen are associated with increased risk of unfavourable functional outcome and short-term mortality. The aim of our study was to determine the relationship between plasma fibrinogen level and long-term risk of death in ischemic stroke patients. Seven hundred thirty six patients (median age 71; 47.1 % men) admitted to the stroke unit within 24 h after stroke were included. Plasma fibrinogen level was measured on day 1 of hospitalisation. Hyperfibrinogenemia was defined as plasma fibrinogen concentration >3.5 g/L. The maximal follow-up period was 84 months. Hyperfibrinogenemia was found in 25.0 % of patients. On multivariate logistic regression analysis, after adjustment for age, stroke severity, atrial fibrillation, smoking, white blood cell count, fever, in-hospital pneumonia and hyperglycemia, hyperfibrinogenemia was associated with increased case fatality (HR 1.71, 95 % CI 1.29–2.26, P < 0.01). Hyperfibrinogenemia predicts the long-term risk of death in ischemic stroke patients.

Brain natriuretic peptide level on admission predicts recurrent stroke after discharge in stroke survivors with atrial fibrillation

OBJECTIVE

We investigated whether brain natriuretic peptide (BNP) levels could be used as a marker to predict recurrent stroke in ischemic stroke survivors.

METHODS

From April 2007 to March 2011, consecutive patients within 24h of onset of ischemic stroke were prospectively enrolled, and admission plasma BNP levels were measured. Survivors were followed up to 12 months after stroke onset. Patients were divided into two groups: the recurrence group and the non-recurrence group. Factors associated with stroke recurrence were investigated by multiple logistic regression analysis.

RESULTS

A total of 793 patients who were alive at hospital discharge were included; 42 (5%) patients had recurrent stroke. There were no differences in BNP levels between groups. With respect to 257 patients with atrial fibrillation (AF), BNP levels were significantly higher in the recurrence group than in the non-recurrence group (426.0 vs. 192.0 pg/mL, P = 0.0007). The optimal cutoff level, sensitivity, and specificity of BNP levels to distinguish the recurrence group from the non-recurrence group were 300.0 pg/mL, 80%, and 73%, respectively. After adjustment for age and sex, plasma BNP ≥ 300.0 pg/mL (OR, 9.2; 95% CI, 1.87-45.01, P = 0.0062) was found to be independently associated with recurrent stroke in stroke survivors with AF.

CONCLUSION

Admission BNP levels can predict recurrent stroke in stroke survivors with AF.

Population-based study of blood biomarkers in prediction of subacute recurrent stroke

BACKGROUND AND PURPOSE

Risk of recurrent stroke is high in the first few weeks after transient ischemic attack or stroke and clinical risk prediction tools have only limited accuracy, particularly after the hyperacute phase. Previous studies of the predictive value of biomarkers have been small, been done in selected populations, and have not concentrated on the acute phase or on intensively treated populations. We aimed to determine the predictive value of a panel of blood biomarkers in intensively treated patients early after transient ischemic attack and stroke.

METHODS

We studied 14 blood biomarkers related to inflammation, thrombosis, atherogenesis, and cardiac or neuronal cell damage in early transient ischemic attack or ischemic stroke in a population-based study (Oxford Vascular Study). Biomarker levels were related to 90-day risk of recurrent stroke as hazard ratio (95% confidence interval) per decile increase, adjusted for age and sex.

RESULTS

Among 1292 eligible patients, there were 53 recurrent ischemic strokes within 90 days. There were moderate correlations (r=0.40-0.61; P<0.0001) between the inflammatory biomarkers and between the cell damage and thrombotic subsets. Associations with risk of early recurrent stroke were weak, with significant associations limited to interleukin-6 (adjusted hazard ratio, 1.12; 1.01-1.24; P=0.033) and C-reactive protein (adjusted hazard ratio, 1.15; 1.02-1.30; P=0.022) after adjusting for age, sex, hypertension, smoking, and diabetes mellitus although P-selectin seemed to predict stroke after transient ischemic attack (adjusted hazard ratio, 1.28; 1.00-1.63; P=0.046).

CONCLUSIONS

In the largest study to date, we found limited predictive use for early recurrent stroke for a panel of inflammatory, thrombotic, and cell damage biomarkers.

Platelet Reactivity in Patients With Stroke and Hyperlipidemia, GPIbα Assessment

The aim of this study was to assess platelet reactivity in patients after ischemic stroke and to investigate the influence of hyperlipidemia (HL) on platelet activity markers. A total of 41 patients after ischemic stroke were divided into the following 2 groups: patients with HL and patients with normolipidemia. Expression of CD42b on resting, thrombin-activated blood platelets, and fibrinogen level was assessed. The CD42b-positive platelets were analyzed using the flow cytometer, anti-CD61, and anti-CD42b monoclonal antibodies. The results confirmed increased platelet reactivity to thrombin in all patients after ischemic stroke manifested by significantly lower CD42b expression and percentage of CD42b(+) platelets after activation by thrombin. The influence of HL on the expression of CD42b on resting and thrombin-activated platelets was not found. However, increased level of fibrinogen but no influence of HL on fibrinogen concentration was observed in patients after ischemic stroke. Increased susceptibility to platelet agonists was found in patients after ischemic stroke in the convalescent phase.

Βeta-fibrinogen gene promoter A -455 allele associated with poor longterm survival among 55-71 years old Caucasian women in Finnish stroke cohort

BACKGROUND

Women die of stroke more often than men. After menopause, the incidence of ischemic stroke increases rapidly. Elevated fibrinogen levels and smoking have been associated with an increased risk of stroke. In gene-cluster haplotype analyses, the beta-fibrinogen (FGB) promoter -455 G/A polymorphic locus was most strongly associated with elevated plasma fibrinogen levels. We investigated whether the FGB -455 G/A polymorphism and smoking might interact with sex on longterm survival of acute stroke sufferers.

METHODS

The Stroke Aging Memory (SAM) cohort comprising 486 consecutive stroke patients (55-85 years, 246 men, 240 women) subjected to clinical and MRI examination was followed over 12.5 years. During this period 347 (71.4%) patients died. The genotypes of the FGB -455 G/A polymorphism were determined by PCR.

RESULTS

The FGB -455 G/A polymorphism genotype distributions were 64.7%, 32.1%, and 3.2% for GG, GA, and AA, respectively. During the follow-up, the FGB -455 A + genotype did not associate with survival, nor was there any genotype-by-smoking interaction on poor outcome in the total study population. However, women aged 55-71 years who carried the FGB -455 A-allele showed worse survival regardless of smoking status compared to non-smoking FGB -455 GG homozygotes (non-smokers, crude HR = 5.21, 95% CI: 1.38-19.7; smokers, crude HR = 7.03, 95% CI: 1.81-27.3). This association persisted in adjusted analyses. No such association was observed for women in the oldest age-group, nor among men.

CONCLUSION

The A + genotype of the FGB -455 G/A polymorphism associated with poor survival among 55-71 years old Caucasian women in the Finnish stroke cohort.