Blood markers for the prognosis of ischemic stroke: a systematic review

Nasal exudate for diagnosis of stroke: fundamental studies through iron fractionation, total iron, and targeted protein determinations

During the last years, there has been an increasing research interest in the analysis of biological fluids requiring non-invasive sampling for biomedical and clinical applications. In this work, we have focused on the nasal exudate with the aim of investigating the potential use of this fluid to know the role of iron in stroke and also for diagnosis. Potential differences in the nasal exudate, collected in swabs, from diagnosed hemorrhagic stroke, ischemic stroke, and control groups were investigated with regard to total iron by inductively coupled plasma-mass spectrometry, iron fractionation studies by size exclusion chromatography together with post-column isotope dilution analysis, and four proteins containing iron (ferritin, transferrin, lactoferrin, and ferroportin) with ELISA kits. All these analyses represent an analytical challenge, considering the rather limited amount of sample (10-40 mg) available, being the nasal exudate extracted from the swab with 300 µL 10 mM Tris/HCl, pH = 7.4. Studies to obtain reliable analytical information, such as the blank contribution of the sampling step, evaluation of the extraction efficiency of the nasal exudate from the swab, and normalization strategies for data treatment, have been carried out. Results showed that despite the limited number of investigated samples, fractionation studies as well as the concentrations of ferritin and ferroportin obtained with ELISA kits showed a differential behavior between the different cohorts.

Evaluating Serum Copeptin as a Promising Biomarker for Predicting Acute Ischaemic Stroke Severity: A Hospital-Based Study on Strokes

BACKGROUND

Stroke is the second cause of mortality and the foremost leading cause of disability globally. Many potential biomarkers have been described to contribute to prognosticating the severity in the acute phase of stroke as well as help with risk stratification. Copeptin, an inactive peptide that is produced in an equimolar ratio to arginine vasopressin and adequately mirrors an individual's stress response to acute illnesses like acute ischaemic stroke as evidenced by elevated or increasing levels is being explored in this study to determine its relationship with acute stroke severity and infarct size on admission.

METHODS

This is a cross-sectional study of 80 neuroimaging-confirmed acute ischaemic patients who presented within seven days of symptom onset and 80 control subjects. The ischaemic stroke cases had stroke severity and infarct volume determined on admission by the National Institute of Health Stroke Scale (NIHSS) and neuroimaging (brain CT/MRI). A baseline serum copeptin level was measured in the study subjects. Spearman correlation and Kruskal Wallis test were used to determine the relationship between serum copeptin level with admission NIHSS and infarct size respectively. The receiver operating characteristic (ROC) curve was calculated to determine the sensitivity and specificity of copeptin to predict severity and outcome.

RESULTS

The mean age of the study group was 61.3 ± 12.7 years with 55.0% males and 45.0% females. The serum level of copeptin was significantly higher in the stroke cases with a median of 28.6 pmol/L (interquartile range (IQR)- 15.4-31.6 pmol/L) versus 8.8 pmol/L (IQR- 3.2- 10.7 pmol/L) among the stroke-free controls (p= 0.001) at a statistically significant level. There was a weak correlation between copeptin and NIHSS calculated at admission to measure stroke severity (r- 0.02, p= 0.873). Patients with infarct sizes in the fourth quartile (infarct sizes greater than 18.78 cm3) had higher copeptin levels, though this was not statistically significant (H= 2.88; p= 0.410). Admission serum copeptin did not show a statistically significant prognostic value in predicting stroke severity and mortality in stroke patients who presented within seven days of symptom onset with an area under curve (AUC) of 0.51 (95% CI: 0.36-0.65; p= 0.982).

CONCLUSION

In this study, copeptin was higher among the stroke cases compared with the stroke-free controls which suggests a significant prognostic value in risk stratification in the acute phase of stroke; however, this did not significantly correlate with stroke severity and thus warrants further study in this field to elucidate it's fascinating potential as a prognostic biomarker (especially in the acute period) as this may enable allocation of a better-focused therapy for stroke patients.

Genetically Determined Plasma Hepatocyte Growth Factor Levels Are Associated With the Risk and Prognosis of Ischemic Stroke

BACKGROUND

Observational studies suggest that hepatocyte growth factor (HGF) is associated with the risk and prognosis of ischemic stroke, but the causality of these associations remains unclear. Therefore, we conducted Mendelian randomization (MR) analyses to explore the associations of genetically determined plasma HGF levels with the risk and prognosis of ischemic stroke.

METHODS

A total of 13 single-nucleotide polymorphisms associated with plasma HGF were selected as genetic instruments based on the data from a genome-wide association study with 21 758 European participants. Summary data about the risk of ischemic stroke were obtained from the MEGASTROKE (Multiancestry Genome-Wide Association Study of Stroke) Consortium with 34 217 ischemic stroke cases and 406 111 controls of European ancestry, and summary data about the prognosis of ischemic stroke were obtained from the GISCOME study (Genetics of Ischaemic Stroke Functional Outcome) with 6165 European patients with ischemic stroke. We conducted an inverse-variance weighted Mendelian randomization analysis followed by a series of sensitivity analyses to evaluate the associations of genetically determined plasma HGF with the risk and prognosis of ischemic stroke.

RESULTS

The primary analyses showed that genetically determined high HGF was associated with an increased risk of ischemic stroke (odds ratio per SD increase, 1.11 [95% CI, 1.04-1.19]; P=1.10×10-3) and poor prognosis of ischemic stroke (odds ratio per SD increase, 2.43 [95% CI, 1.76-3.52]; P=6.35×10-8). In the secondary analysis, genetically determined plasma HGF was associated with a high risk of large atherosclerotic stroke (odds ratio per SD increase, 1.39 [95% CI, 1.18-1.63]; P=5.08×10-5) but not small vessel stroke and cardioembolic stroke. Mendelian randomization-Egger regression showed no directional pleiotropy for all associations, and the sensitivity analyses with different Mendelian randomization methods further confirmed these findings.

CONCLUSIONS

We found positive associations of genetically determined plasma HGF with the risk and prognosis of ischemic stroke, suggesting that HGF might be implicated in the occurrence and development of ischemic stroke.

Which one predicts mortality better in acute ischemic stroke: negative vs positive acute-phase reactants

AIM

The aim of the study is to investigate the relationship between negative acute-phase reactants and positive acute-phase reactants with in-hospital mortality in patients diagnosed with acute ischemic stroke (AIS) in the emergency department (ED).

METHODS AND MATERIALS

Patients aged 18 and older who presented to the ED of a tertiary hospital with AIS were included in the study. Demographic and clinical characteristics, laboratory parameters, acute-phase reactants, National Institutes of Health Stroke Scale (NIHSS), and outcome data of the included patients were recorded on a standard data form.

RESULTS

A total of 588 patients were included in the study. When the in-hospital mortality of patients was examined, the mortality rate was 17.7%. In the analysis for predicting mortality, it was determined that albumin had the highest predictive power between the area under the curve (AUC) and the determined predictive values (AUC: 0.759, 95% CI 0.707-0.810, p < 0.001). The analyses of the study data revealed that albumin (<0.001) and TF (p = 0.049), which are negative acute-phase reactants, were independent predictors of mortality. According to our study data, in patients with AIS, for each unit decrease in albumin level at the time of ED admission, the risk of mortality increased by 0.868 times, and for each unit decrease in TF level, the risk of mortality increased by 0.593 times.

CONCLUSION

According to the study data, albumin and TF levels, which are negative acute-phase reactants, are independent determinants of in-hospital mortality in patients with acute ischemic stroke in the emergency department.

White matter hyperintensity, parent artery steno-occlusion, and neurological deterioration in anterior circulation single subcortical infarction patients

BACKGROUND

The evidence for the association between white matter hyperintensity (WMH) severity and neurological deterioration (ND) in patients with single subcortical infarction (SSI) remains unclear and whether the association between them is modified by anterior circulation parent artery steno-occlusion (PAS) is unknown. Herein, we aimed to prospectively investigate the internal relevance.

METHODS

In this prospective study, the severity of WMH and PAS were assessed in 288 consecutive patients with anterior circulation SSI arriving at our hospital, a tertiary teaching hospital affiliated with Fudan University, 24 h after onset from January 2017 to December 2018. The multivariable logistic regression model was used to estimate the association between WMH severity and the risk of ND within 7 days after stroke onset as well as the interactive effect between WMH severity and PAS on ND among patients with SSI.

RESULTS

PAS modified the association between WMH severity and ND among patients with SSI (pinteraction = .029). After multivariate adjustment, the odds ratios of moderate-severe WMH associated with ND were 1.61 (95% CI, 0.50-5.19; ptrend = .428) for patients with PAS, and 0.37 (95% CI, 0.14-0.97; ptrend = .043) for those without PAS. Adding WMH severity to conventional risk factors improved risk prediction for ND in patients without PAS (net reclassification improvement: 48.2%, p = .005; integrated discrimination index: 2.5%, p = .004) but not in those with PAS.

CONCLUSION

There was a modified effect of PAS on the association between WMH severity and ND within 7 days after stroke onset among patients with anterior circulation SSI, which deserves more research attention. WMH was negatively associated with ND in anterior circulation SSI patients without PAS.

Neuron-specific enolase at admission as a predictor for stroke volume, severity and outcome in ischemic stroke patients: a prognostic biomarker review

An ideal blood biomarker for stroke should provide reliable results, enable fast diagnosis, and be readily accessible for practical use. Neuron-specific enolase (NSE), an enzyme released after neuronal damage, has been studied as a marker for brain injury, including cerebral infarction. However, different methodologies and limited sample sizes have restricted the applicability of any potential findings. This work aims to determine whether NSE levels at Emergency Department (ED) admission correlate with stroke severity, infarcted brain volume, functional outcome, and/or death rates. A systematic literature review was performed using PubMed, Embase, and Scopus databases. Each reviewer independently assessed all published studies identified as potentially relevant. All relevant original observational studies (cohort, case-control, and cross-sectional studies) were included. Eleven studies (1398 patients) met the inclusion criteria. Among these, six studies reported a significant correlation between NSE levels and stroke severity, while only one found no association. Four studies indicated a positive relationship between infarcted brain volume assessed by imaging and NSE levels, in contrast to the findings of only one study. Four studies identified an association related to functional outcome and death rates, while three others did not reach statistical significance in their findings. These data highlight that NSE levels at ED admissions proved to be a promising tool for predicting the outcome of ischemic stroke patients in most studies. However, they presented high discrepancies and low robustness. Therefore, further research is necessary to establish and define the role of NSE in clinical practice.

Near Infrared Emissive Lanthanide Luminescence Nanoparticle Used in Early Diagnosis and Brain Temperature Detection for Ischemic Stroke

Ischemic stroke (IS) is one of the most dangerous medical conditions resulting in high mortality and morbidity. The increased brain temperature after IS is closely related to prognosis, making it highly significant for the early diagnosis and the progression evaluation of IS. Herein, a temperature-responsive near infrared (NIR) emissive lanthanide luminescence nanoparticle is developed for the early diagnosis and brain temperature detection of IS. After intravenous injection, the nanoparticles can pass through the damaged blood-brain barrier of the ischemic region, allowing the extravasation and enrichment of nanoparticles into the ischemic brain tissue. The NIR luminescence signals of the nanoparticles are used not only to judge the location and severity of the cerebral ischemic injury but also to report the brain temperature variation in the ischemic area through a visualized way. The results show that the designed nanoparticles can be used for the early diagnosis of ischemic stroke and minimally invasive temperature detection of cerebral ischemic tissues in transient middle cerebral artery occlusion mice model, which is expected to make the clinical diagnosis of ischemic stroke more rapid and convenient, more accurately evaluate the state of brain injury in stroke patients and also guide stroke hypothermia treatment.

Role of Cardiac Risk Scores in Clinical Use to Predict Outcomes of Acute Ischemic Stroke

Introduction

Acute coronary syndromes and ischemic stroke have similar risk factors. Risk scores help to identify disease severity in both diseases. We aimed to evaluate if HEART (History, ECG, Age, Risk factors, and Troponin) score could predict re-hospitalization, recurrent cardiac/cerebrovascular events risk, and mortality within 1-year follow-up in patients presenting with acute ischemic stroke.

Methods

Patients hospitalized with a diagnosis of acute ischemic stroke in our tertiary center between 2019 and 2021 were included in this retrospective study. CHA2DS2-VASc and HEART scores on admission were calculated. In-hospital, 1-month, and 1-year mortalities, as well as re-hospitalization due to recurrent ischemic (cardiac/cerebral), were defined as major adverse cardiac and cerebrovascular events (MACCE), and occurrence of MACCE was accepted as the primary endpoint of the study. Comparative statistical and regression analyses were obtained.

Results

A total of 297 patients were included. The mortality rate for 30 days was 7.4% and 1 year was 20.5%. HEART and CHA2DS2-VASc scores were found independent risk factors associated with the occurrence of MACCE. Patients who experienced MACCE had higher HEART and CHA2DS2-VASc scores. Meanwhile, HEART score had better prognostic accuracy than CHA2DS2-VASc score when a cutoff value of 3.5 was set, which is associated with 84.7% sensitivity and 75.2% specificity in the prediction of MACCE.

Conclusion

HEART score is effective in determining re-hospitalization and recurrent cerebral ischemic event risk as well as mortality within 30 days and 1 year in patients presenting with acute ischemic stroke. Thus, concomitant use of HEART and CHA2DS2-VASc scores may provide better characterization of worse prognosis in ischemic stroke patients with high sensitivity and specificity.

Elevated Troponin I as a Marker for Unfavorable Outcomes in Acute Ischemic Stroke

OBJECTIVE

To assess if elevated cardiac troponin I (cTnI) serves as a sign of unfavorable functional outcomes in ischemic stroke.

METHODS

In this single-center prospective cohort study, 100 consecutive patients admitted with acute ischemic stroke (normal troponin I group n = 52, raised troponin I group n = 48) were included. Hospital mortality was documented in both groups; the remaining patients were followed up to 90 days. Then two groups were compared in terms of unfavorable short-term outcomes (Modified Rankin Scale > 3) and mortality. Multivariate logistic regression was conducted to determine the predictive value of elevated cTnI. The Kaplan-Meier curve was drawn and compared to determine the difference in survival between the two groups. To find out the most probable cut-off level for an unfavorable outcome, a receiver operating characteristic (ROC) analysis was conducted.

RESULT

 A higher frequency of coronary artery disease (p=0.030), higher National Institutes of Health Stroke Scale (NIHSS) (p=0.008) score, and lower Glasgow Coma Scale (GCS) (p=0.002) was observed in raised troponin I group. Even after the exclusion of confounding elevated troponin I was found to be an independent predictor of unfavorable outcomes (adjusted odds ratio, OR 8.25 {95% confidence interval, CI: 2.65-25.75}; p<0.001). The patients with raised troponin I had a significantly lower rate of survival after 90 days (p=0.022). The elevated troponin I was observed to have a significantly high accuracy (p<0.001; area under curve, AUC: 0.768 {moderate accuracy}, 95% CI: 0 .676 to 0.861) in predicting unfavorable outcomes.

CONCLUSION

Elevated cTnI is independently associated with unfavorable short-term outcomes. It is also associated with a lower rate of survival.

Risk stratification of atrial fibrillation and stroke using single nucleotide polymorphism and circulating biomarkers

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia, and it causes a high rate of complications such as stroke. It is known that AF begins as paroxysmal form and gradually progresses to persistent form, and sometimes it is difficult to identify paroxysmal AF (PAF) before having stroke. The aim of this study is to evaluate the risk of PAF and stroke using genetic analysis and circulating biomarkers.

MATERIALS AND METHODS

A total of 600 adult subjects were enrolled (300 from PAF and control groups). Peripheral blood was drawn to identify the genetic variation and biomarkers. Ten single nucleotide polymorphisms (SNPs) were analyzed, and circulating cell-free DNA (cfDNA) was measured from plasma. Four microRNAs (miR-99a-5p, miR-192-5p, miR-214-3p, and miR-342-5p) were quantified in serum using quantitative RT-PCR.

RESULTS

Genotyping identified 4 single nucleotide polymorphisms (SNPs) that were significantly associated with AF (rs6817105, rs3807989, rs10824026, and rs2106261), and the genetic risk score using 4 SNPs showed the area under the curve (AUC) of 0.631. Circulating miRNAs and cfDNA did not show significant differences between PAF and control groups. The concentration of cfDNA was significantly higher in patients with a history of stroke, and the AUC was 0.950 to estimate the association with stroke.

CONCLUSION

The risk of AF could be assessed by genetic risk score. Furthermore, the risk of stroke might be evaluated by plasma cfDNA level.

A Prediction Model for Rapid Identification of Ischemic Stroke: Application of Serum Soluble Corin

Objective

Rapid identification is critical for ischemic stroke due to the very narrow therapeutic time window. The objective of this study was to construct a diagnostic model for the rapid identification of ischemic stroke.

Methods

A mixture population constituted of patients with ischemic stroke (n = 481), patients with hemorrhagic stroke (n = 116), and healthy individuals from communities (n = 2498) were randomly resampled into training (n = 1547, mean age: 55 years, 44% males) and testing (n = 1548, mean age: 54 years, 43% males) samples. Serum corin was assayed using commercial ELISA kits. Potential risk factors including age, sex, education level, cigarette smoking, alcohol consumption, obesity, blood pressure, lipids, glucose, and medical history were obtained as candidate predictors. The diagnostic model of ischemic stroke was developed using a backward stepwise logistic regression model in the training sample and validated in the testing sample.

Results

The final diagnostic model included age, sex, cigarette smoking, family history of stroke, history of hypertension, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, fasting glucose, and serum corin. The diagnostic model exhibited good discrimination in both training (AUC: 0.910, 95% CI: 0.884-0.936) and testing (AUC: 0.907, 95% CI: 0.881-0.934) samples. Calibration curves showed good concordance between the observed and predicted probability of ischemic stroke in both samples (all P>0.05).

Conclusion

We developed a simple diagnostic model with routinely available variables to assist rapid identification of ischemic stroke. The effectiveness and efficiency of this model warranted further investigation.

COVID-19 Vaccination Is Associated with a Better Outcome in Acute Ischemic Stroke Patients: A Retrospective Observational Study

Background: It is unclear whether and how COVID-19 vaccination may affect the outcome of patients with acute ischemic stroke (AIS). We investigated this potential association in a retrospective study by comparing previously vaccinated (VAX) versus unvaccinated (NoVAX) stroke patients. Methods: We collected clinical reports for all consecutive AIS patients admitted to our hospital and evaluated the outcome predictors in VAX and NoVAX groups. Adjustments were made for possible confounders in multivariable logistic regression analysis, and adjusted hazard ratios were calculated. Results: A total of 466 AIS patients (287 VAX and 179 NoVAX) were included in this study. The NIHSS score at discharge and mRS score at a 3-month follow-up visit were significantly lower in VAX patients compared to NoVAX patients (p < 0.001). Good outcomes (mRS 0−2) were significantly associated with COVID-19 vaccination before AIS (adjusted hazard ratio, 0.400 [95% CI = 0.216−0.741]). Conclusions: The observation that COVID-19 vaccination can influence the outcome of AIS provides support for further studies investigating the role of immunity in ischemic brain damage.

Multiplex array analysis of serum cytokines offers minimal predictive value for cognitive function in the subacute phase after stroke

OBJECTIVE

The effects of inflammation on post-stroke cognitive function are still unclear. This study investigated the correlation between the Th17-related cytokines in peripheral blood and post-stroke cognitive function after ischemic stroke in the subacute phase.

DESIGN

A retrospective cohort study.

SETTING

Academic acute inpatient rehabilitation facility.

PARTICIPANTS

One hundred and fourteen patients with first ischemic stroke were categorized as the poor cognitive recovery group (n = 58) or good cognitive recovery group (n = 56) based on their cognitive MRFS efficiency.

INTERVENTIONS

All subjects received routine physical, occupational, and speech-language pathology therapy.

MAIN OUTCOME MEASURES

Serum cytokines/chemokine (IL-1 β, IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-12p70, IL-13, IL-15, IL-17A, IL-17E, IL-17F, IL-21, IL-22, IL-23, IL-27, IL-28A, IL-31, IL-33, GM-CSF, IFN-γ, MIP-3 α, TNF-α, and TNF-β) levels were measured in duplicate using Human Th17 magnetic bead panel and multiplex array analysis (Luminex-200 system). The primary functional outcome was a gain in functional independence measure (FIM) cognitive subscore at discharge. The secondary outcome measures were FIM total score at discharge, length of stay in the hospital, and discharge destination. Cognitive Montebello Rehabilitation Factor Score (MRFS) and cognitive MRFS efficiency were calculated. Demographic and clinical characteristics were obtained from the medical record.

RESULTS

The good cognitive recovery group had an interesting trend of higher IL-13 than the poor cognitive recovery group (good cognitive recovery group 257.82 ± 268.76 vs. poor cognitive recovery group 191.67 ± 201.82, p = 0.049, unit: pg/ml). However, Pearson's correlation analysis showed no significant correlation between cytokine levels and gain of cognition, cognitive MRFS, or cognitive MRFS efficiency. Receiver operating characteristic (ROC) analysis of cytokines also suggested a low accuracy of prediction as a predictor for post-stroke cognitive recovery improvement.

CONCLUSION

Our preliminary findings suggested that the level of serum cytokines had minimal predictive value for the recovery of cognitive function during the subacute inpatient rehabilitation after stroke.

Th1/Th2 polarization of peripheral immune response in atherothrombotic and cardioembolic stroke: a prospective study

Compelling evidence suggest a key role of immune system in the development and progression of ischemic stroke. Although the balance between proinflammatory CD4 + T helper (Th)-1 lymphocytes, expressing T-bet transcription factor, and anti-inflammatory Th2 cells expressing GATA3 seems to influence the outcome in experimental stroke, the role of peripheral immune response in acute stroke patients is poorly understood. We aimed to evaluate the peripheral Th1/Th2 balance in acute atherothrombotic (ATHS) and cardioembolic stroke (CES) patients and in age- and sex-matched healthy subjects. Using flow cytometry, we analyzed the percentage of CD4 + T-bet + T cells and CD4 + GATA3 + T cells from peripheral blood of ATHS and CES patients (2,4 and 7 days after stroke onset). Patients and controls were screened for infectious conditions, autoimmune, inflammatory, or cancerous diseases. On day 2 circulating CD4 + T-bet + T cells were significantly higher in stroke patients compared to controls, and in ATHS compared to CES and controls. On day 7, we observed a significant increase of CD4 + T-bet + T cells in both ATHS and CES patients compared to baseline. No difference was observed in circulating CD4 + GATA3 + T cells among ATHS, CES patients, and controls. These data suggest that circulating CD4 + T-bet + T cells could be useful marker indicating atherothrombotic genesis of stroke and provide new insight into the peripheral adaptive immune response in acute stroke.

The relationship between age shock index, and severity of stroke and in-hospital mortality in patients with acute ischemic stroke

BACKGROUND

Shock index (SI) has been reported to help us predict adverse prognosis in patients with acute ischemic stroke (AIS). However, the prognostic value of age SI and age modified shock index (MSI) in acute ischemic stroke is unknown. In our study, we aimed to examine the association between the severity of the stroke and in-hospital mortality, age SI and age MSI in patients with AIS.

METHODS

A total of 256 patients were enrolled in this study. The National Institutes of Health Stroke Scale (NIHSS) was used to determine the severity of stroke. Patients were divided into two groups according to the NIHSS score calculated during hospitalization (NIHSS>14: severe disability group, NIHSS<15: moderate and mild disability group). Shock indexes were calculated using the blood pressure and heart rate values measured as a result of the cardiovascular examinations of the patients. We looked for correlations between increased NIHSS and in-hospital mortality with age shock index and age modified shock index.

RESULTS

Age SI and age MSI values were higher in the severe disability group than those without severe disability, and the results were statistically significant (p<0.001, p<0.001, respectively). Also, a positive correlation was determined between the height of NIHSS and the age SI and the age MSI (p=0.002, r=0.197, p=0.001, r=0.215, respectively). Thirty-two (12.5%) of 256 patients included in the study died during hospitalization. Patients who died were older (77.1±11.0 vs. 67.5±13.5, respectively; p<0.001). According to Point-Biserial correlation analysis, there was a positive correlation between mortality and age SI, and age MSI (p<0.001, r=0.258 ve p<0.001, r=0.274, respectively).

CONCLUSIONS

As a result of our study, the relationship between stroke severity and increasing age SI and age MSI was significant and there was a positive correlation. In addition, there was a significant and positive relationship between in-hospital mortality and age SI and age MSI.

Elevated Serum Lactate Dehydrogenase Predicts Unfavorable Outcomes After rt-PA Thrombolysis in Ischemic Stroke Patients

Background and Purpose

Currently, acute ischemic stroke (AIS) is one of the most common and serious diseases in the world and is associated with very high mortality and morbidity even after thrombolysis therapy. This study aims to research the relationship between lactic dehydrogenase (LDH) and prognosis in AIS patients treated with intravenous rtPA.

Method

This study (a Multicenter Clinical Trial of Revascularization Treatment for Acute Ischemic Stroke, TRAIS) included 527 AIS patients in 5 cooperative medical institutions in China from January 2018 to February 2021. The primary outcome was major disability and death within 3 months (mRS score of 3–6), and the secondary outcomes were early neurological improvement (ENI), early neurological deterioration (END), moderate-severe cerebral edema (CE), and symptomatic intracranial hemorrhage (sICH).

Results

The mean age of the 527 patients was 65.6 ± 11.7 years, and the median baseline NIHSS score was 4 (interquartile range, 2–7). The median serum LDH level was 184 U/L (interquartile range, 163–212 U/L). In total, 287 (54.5%) patients acquired ENI, 68 (13.0%) patients suffered END, 53 (12.1%) patients were observed with moderate-severe CE, and 28 (6.2%) patients showed sICH. Within 3 months, 127 (25.15%) patients experienced the primary outcome and 42 (8.3%) patients died. Serum LDH levels before thrombolysis showed an independent association with the risk of primary outcome [adjusted odds ratio, 3.787; (95% CI, 1.525–9.404); P = 0.014]. When log-transformed LDH increased each standard deviation, the risk of primary outcome was raised by 80.1% (95% CI, 28.9–251.7%). A positive linear dependence between the risk of primary outcome and serum LDH levels (P of linearity = 0.0248, P of non-linearity = 0.8284) was shown in multivariable-adjusted spline regression models. Pre-thrombolysis LDH quartile also provided a conventional risk model and significant improvement of the prediction for clinical outcomes, with a net reclassification improvement index (NRI) = 41.86% (P < 0.001) and integrated discrimination improvement (IDI) = 4.68% (P < 0.001).

Conclusions

Elevated serum LDH levels predicted unfavorable clinical outcomes after intravenous thrombolysis in AIS patients.

Short-Term Prognostic Predictive Evaluation in Female Patients With Ischemic Stroke: A Retrospective Cross-Sectional Study

Introduction and Aim

Stroke is a disease with high mortality and morbidity. Although studies are generally performed on all patients with stroke, it is known that gender has an effect on etiology and prognosis. This study aimed to determine the importance of clinical stroke scales and laboratory markers in determining the short-term prognosis of female patients with ischemic stroke of anterior circulation.

Materials and Methods

The study was planned as a retrospective and cross-sectional study. SEDAN score, the National Institutes of Health stroke scale (NIHSS), the Modified Rankin Scale (mRS), the Glasgow Coma Scale (GCS), and THRIVE score applied to the patients at the time of admission were recorded. Admission blood glucose, hemoglobin, leukocyte, urea, albumin, and blood lipid levels were evaluated. The relationship of all these parameters with in-hospital prognosis, mortality, and disability at discharge was examined. The relationship between groups and data was analyzed using the SPSS package program after the normality analysis.

Results

In this study, there were 733 female patients with stroke with a mean age of 69.53 ± 14.51 years and 858 male patients with stroke with a mean age of 64.27 ± 13.29 years. Hospitalization time, length of stay in the intensive care unit, ventilation need rate, mortality, and dependency rate were higher in female patients (p = 0.001). The NIHSS, SEDAN, and THRIVE scores were higher in female patients who had in-hospital mortality, had a poor prognosis, and who were discharged as dependent (p = 0.001). GCS was lower in this patient group (p = 0.001). Blood glucose, creatinine, leukocytes, urea, and CRP levels were higher; the albumin and hemoglobin levels was lower in female patients who had fatal outcomes (p = 0.009, 0.001, 0.001, 0.001, 0.001, and 0.020; respectively). In female patients who were dependent at discharge, blood urea, glucose, and CRP levels were higher and the albumin levels were lower than those in female patients who achieved functional independence (p = 0.001, 0.016, 0.002, and 0.001, respectively).

Conclusion

Our study showed that the short-term prognosis is worse in female patients who had an ischemic stroke of anterior circulation. It also revealed some clinical and laboratory parameters that could predict this situation. More intensive monitoring may be needed to improve prognosis in female patients.

Association of serum growth differentiation factor-15 levels with the risks of death and vascular events in patients with ischemic stroke: The role of diabetes

BACKGROUND AND AIMS

Researchers have not determined whether the association between growth differentiation factor-15 (GDF-15) levels and stroke outcomes is modified by the diabetes status. We aimed to evaluate the prognostic value of GDF-15 among patients with ischemic stroke stratified by diabetes.

METHODS AND RESULTS

A total of 3001 patients with ischemic stroke were selected from the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) and included in this study. The primary outcome was a composite outcome of death and vascular events at 3 months after acute ischemic stroke. An elevated GDF-15 level was significantly associated with the primary outcome in patients with diabetes but not in those without diabetes (p_interaction = 0.038). The multivariate-adjusted hazard ratio (95% confidence intervals) for the primary outcome was 3.33 (1.07-10.35) when 2 extreme tertiles were compared, and a linear association between GDF-15 levels and the primary outcome was observed in patients with diabetes (p for linearity = 0.046). The addition of serum GDF-15 to conventional risk factors improved the risk prediction for the primary outcome in patients with diabetes (net reclassification improvement: 31.98%, p = 0.043; integrated discrimination index: 0.85%, p = 0.034) but not in those without diabetes.

CONCLUSIONS

A modifying effect of the diabetes status on the association between serum GDF-15 levels and ischemic stroke prognosis was observed. Elevated serum GDF-15 levels were associated with the primary outcome within 3 months after ischemic stroke in patients with diabetes, suggesting that GDF-15 may be an important prognostic factor for ischemic stroke in patients with diabetes.

A Combined Clinical and Serum Biomarker-Based Approach May Allow Early Differentiation Between Patients With Minor Stroke and Transient Ischemic Attack as Well as Mid-term Prognostication

Background: Early differentiation between transient ischemic attack (TIA) and minor ischemic stroke (MIS) impacts on the patient's individual diagnostic work-up and treatment. Furthermore, estimations regarding persisting impairments after MIS are essential to guide rehabilitation programs. This study evaluated a combined clinical- and serum biomarker-based approach for the differentiation between TIA and MIS as well as the mid-term prognostication of the functional outcome, which is applicable within the first 24 h after symptom onset. Methods: Prospectively collected data were used for a retrospective analysis including the neurological deficit at admission (National Institutes of Health Stroke Scale, NIHSS) and the following serum biomarkers covering different pathophysiological aspects of stroke: Coagulation (fibrinogen, antithrombin), inflammation (C reactive protein), neuronal damage in the cellular [neuron specific enolase], and the extracellular compartment [matrix metalloproteinase-9, hyaluronic acid]. Further, cerebral magnetic resonance imaging was performed at baseline and day 7, while functional outcome was evaluated with the modified Rankin Scale (mRS) after 3, 6, and 12 months. Results: Based on data from 96 patients (age 64 ± 14 years), 23 TIA patients (NIHSS 0.6 ± 1.1) were compared with 73 MIS patients (NIHSS 2.4 ± 2.0). In a binary logistic regression analysis, the combination of NIHSS and serum biomarkers differentiated MIS from TIA with a sensitivity of 91.8% and a specificity of 60.9% [area under the curve (AUC) 0.84]. In patients with NIHSS 0 at admission, this panel resulted in a still acceptable sensitivity of 81.3% (specificity 71.4%, AUC 0.69) for the differentiation between MIS (n = 16) and TIA (n = 14). By adding age, remarkable sensitivities of 98.4, 100, and 98.2% for the prediction of an excellent outcome (mRS 0 or 1) were achieved with respect to time points investigated within the 1-year follow-up. However, the specificity was moderate and decreased over time (83.3, 70, 58.3%; AUC 0.96, 0.92, 0.91). Conclusion: This pilot study provides evidence that the NIHSS combined with selected serum biomarkers covering pathophysiological aspects of stroke may represent a useful tool to differentiate between MIS and TIA within 24 h after symptom onset. Further, this approach may accurately predict the mid-term outcome in minor stroke patients, which might help to allocate rehabilitative resources.

Red Cell Distribution Width as a Predictor of One-Year Prognosis and Mortality of Endovascular Therapy for Acute Anterior Circulation Ischemic Stroke

OBJECTIVES

To investigate if Red cell distribution width (RDW) can predict long-term prognosis in patients with acute ischemic stroke (AIS) receiving endovascular therapy (EVT).

METHODS

In this study, 102 AIS patients treated with EVT were retrospectively recruited. Clinical profiles and prognoses were collected for all patients. The patients were grouped following the modified ranking scale (MRS) scoring system as given below: a group of favorable functional outcome: 0-2; and a group of unfavorable functional outcome: 3-6.

RESULTS

In multivariate logistic regression, RDW (odds ratio [OR] = 2.799, 95 % confidence interval [CI] = 1.425-5.489; p = 0.003) was an independent predictor of unfavorable functional outcome, and it (OR, 1.929; 95% CI, 1.075-3.458; p = 0.028) was also an independent biomarker for all-cause mortality. The best predictive RDW cut-off value was 13.05% (sensitivity: 93.1%, specificity: 60.3%, AUC: 0.806, p < 0.001).

CONCLUSIONS

The results imply that pre-RDW is a reliable predictor of one-year prognosis and mortality after EVT in acute anterior circulation stroke patients.

Predictive Value of Insulin Resistance as Determined by Homeostasis Model Assessment in Acute Ischemic Stroke Patients: A Systematic Review and Meta-Analysis

Studies on association between homeostasis model assessment of insulin resistance (HOMA-IR) and adverse outcomes have yielded conflicting results in patients with acute ischemic stroke (AIS). This meta-analysis aimed to assess the predictive value of HOMA-IR in AIS patients. Two authors comprehensively searched PubMed and Embase databases until February 28, 2021. All observational studies investigating the association between HOMA-IR and adverse outcomes in AIS patients were included. Outcome measures were poor functional outcome (Modified Rankin Scale≥3), all-cause mortality, stroke recurrence, and neurologic worsening. Seven studies (eight articles) involving 8330 AIS patients were identified. For the highest versus lowest HOMA-IR, the pooled risk ratio (RR) of poor functional outcome was 2.55 (95% CI 1.76-3.70) after adjustment of conventional confounding factors. In addition, elevated HOMA-IR was associated with higher risk of neurologic worsening (RR 1.93; 95% CI 1.15-3.26). However, there were conflicting findings on the association of HOMA-IR with stroke recurrence and all-cause mortality. This meta-analysis confirms that HOMA-IR is significantly associated with an increased risk of poor functional outcome in patients with AIS. However, interpretation of the results of mortality, stroke recurrence, and neurologic worsening should be done with caution due to small number of studies available.

Exploring potential serum levels of Homocysteine, interleukin-1 beta, and apolipoprotein B 48 as new biomarkers for patients with ischemic stroke

BACKGROUND

Stroke is the second leading cause of death worldwide with heterogeneous characteristics. The subtypes of stroke are due to different pathophysiological regulations and causes. This study aimed to investigate the correlation of serum levels of apolipoprotein B 48, interleukin-1β and Homocysteine with BMI in patients with ischemic stroke (IS).

METHODS

Over one hundred controls (120) and an equal number of IS patients, including 31 women and 89 men, were recruited to participate in the case-control study conducted at Imam Reza Hospital (Tabriz, Iran) from February 2019 to March 2020. We measured serum levels of apolipoprotein B 48, interleukin-1β, and Homocysteine. Receiver operating characteristic analysis (ROC) was performed to evaluate the diagnostic value of these indices in patients and control groups.

RESULTS

The mean serum levels of apolipoprotein B 48, interleukin-1β, and Homocysteine, were significantly increased in the experimental group compared to the control group with a p-value of 0.001. The ROC curve analysis showed that the area under the curve for apo B48, IL -1β, hs-CRP, and Homocysteine serum levels were 0.94, 0.98, 0.99, and 1, respectively.

CONCLUSIONS

The results of our current study show that the determination of serum levels of apolipoprotein B 48, interleukin-1β, and Homocysteine can potentially be used to monitor and diagnose IS patients. However, there was no statistically significant correlation between serum levels of apolipoprotein B 48, interleukin 1β and Homocysteine and BMI in the patient group. However, there was a statistically significant inverse correlation between serum levels of high-sensitivity C-reactive protein (hs-CRP) and BMI in the patient group.

Salivary cytokine profile in patients with ischemic stroke

Inflammation plays a crucial role in stroke pathogenesis. Thus, it is not surprising that cytokines, chemokines, and growth factors have been advocated in stroke diagnostics. Our study is the first to evaluate the salivary cytokine profile in patients with ischemic stroke. Twenty-five patients with subacute ischemic stroke and an age-, sex-, and oral hygiene status-matched control group were enrolled in the study. The number of patients was set a priori based on our previous experiment (α = 0.05, test power = 0.9). Salivary concentrations of tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), and interleukin 10 (IL-10) were assessed using an ELISA method. We showed that salivary TNF-α and IL-6 were significantly higher, whereas IL-10 content was statistically lower in both non-stimulated (NWS) and stimulated (SWS) whole saliva of ischemic stroke patients. However, evaluation of cytokines in NWS rather than in SWS may be of greater diagnostic value. Of particular note is salivary TNF-α, which may indicate cognitive/physical impairment in post-stroke individuals. This parameter distinguishes stroke patients from healthy controls and correlates with cognitive decline and severity of functional impairment. It also differentiates (with high sensitivity and specificity) stroke patients with normal cognition from mild to moderate cognitive impairment. Saliva may be an alternative to blood for assessing cytokines in stroke patients, although further studies on a larger patient population are needed.

Prognostic molecular markers for motor recovery in acute hemorrhagic stroke: A systematic review

BACKGROUND AND AIMS

Molecular biomarkers are associated with poor prognosis in ischemic stroke individuals. However, it might not be generalizable to post-acute hemorrhagic stroke since the underlying mechanisms of this brain damage differ from those found in ischemic stroke. The main purpose of this review was to synthesize the potential predictive molecular biomarkers for motor recovery following acute hemorrhagic stroke.

MATERIALS AND METHODS

An electronic search was conducted by 2 independent reviewers in the following databases: PubMed (Medline), EMBASE, Web of Science, and CINAHL. We included studies that addressed the following: collected blood, urine, or cerebrospinal fluid samples within 72 h after hemorrhagic stroke and that reported the prognostic association with functional motor recovery for each molecular biomarker. Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers.

RESULTS

Twelve thousand, five hundred and sixty-four studies were identified and 218 were considered eligible. Finally, we included 70 studies, with 96 biomarkers analyzed, of which 61 were considered as independent prognostic biomarkers, and 10 presented controversial results.

CONCLUSION

This systematic review shows that motor functional recovery can be predicted by 61 independent prognostic molecular biomarkers assessed in the acute phase after a hemorrhagic stroke.

Biomarkers in the prognostic evaluation of ischemic stroke: Is there benefit in the measurements of TREM-1 and TREM-2 in the acute phase?

BACKGROUND AND PURPOSE

Triggering receptors expressed on myeloid cells 1 and 2 (TREM-1 and TREM-2) are cell surface receptors important for modulation of microglia immune response. In this study, we evaluate serum levels of TREM-1 and TREM-2 as potential biomarkers in acute ischemic stroke (AIS).

MATERIAL AND METHODS

Prospective cohort study of 50 patients with AIS admitted at our hospital. Serum TREM-1 and TREM-2 was evaluated within 24 h of the acute event and on the third and fifth days after the stroke. Neurological stroke severity and global disability were determined with the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at the same three times and at the time of hospital discharge.

RESULTS

TREM-1 and TREM-2 levels were elevated in stroke. TREM-1, but not TREM-2, exhibited correlations with NIHSS and mRS within 24 h (NIHSS and TREM-1: r_S = 0.31, p = 0.029; mRS and TREM-1: r_S = 0.32, p = 0.023). The serum level of TREM-1 within 24 h correlated with the neurological outcomes at hospital discharge (NIHSS and TREM-1: p = 0.021; mRS and TREM-1: p = 0.049). The serum concentrations of TREM-1 protein within 24 h after stroke was significantly higher in patients with poor outcome (mRS > 2) at hospital discharge (p = 0.021). After Exact Logistic Regression, large segmental stroke (O.R. = 4.14; 95CI = 1.07-16.09; p = 0.040) and initial sTREM levels (O.R. = 1.02; 95CI 1.00-1.04; p = 0.045) remained independent prognostic factors for AIS poor outcome (mRS > 2).

CONCLUSION

In our study, TREM-1 and TREM-2 were significantly increased in AIS. Early elevation of TREM-1 correlated with stroke severity and it was an independent prognostic factor for stroke outcome.

C-Reactive Protein Levels and Clinical Prognosis in LAA-Type Stroke Patients: A Prospective Cohort Study

Methods

We prospectively included 200 patients with LAA-type AIS and tested their CRP levels on admission. We followed these patients consecutively. The primary outcome was an adverse event, defined as a modified Rankin Scale score of 2-6 at months 3, 6, and 12 after discharge. A logistic regression model was used to analyze the relationship between CRP and the functional outcome of LAA stroke.

Results

We divided 200 patients into 3 groups evenly based on CRP level. After adjustment for gender, age, smoking history, drinking history, history of hyperlipidemia, history of diabetes, lipid levels, and blood glucose levels, logistic regression showed that the incidence of LAA-type AIS poor outcome was positively associated with CRP level at admission, whether it was 3 months, 6 months, or 12 months after discharge, respectively (OR: 2.574, 95% CI: 1.213-5.463; OR: 2.806, 95% CI: 1.298-6.065; OR: 2.492, 95% CI: 1.167-5.321. In the highest tertile vs. the lowest tertile as a reference), and both were statistically different.

Conclusions

High CRP level predicts poor functional outcome in LAA-type AIS patients, which provides a strong basis for clinicians to make treatment decisions for these patients.

Prognostic Metrics Associated with Inflammation and Atherosclerosis Signaling Evaluate the Burden of Adverse Clinical Outcomes in Ischemic Stroke Patients

BACKGROUND

Conventional prognostic risk factors can only partly explain the adverse clinical outcomes after ischemic stroke. We aimed to establish a set of prognostic metrics and evaluate its public health significance on the burden of adverse clinical outcomes of ischemic stroke.

METHODS

All patients were from the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS). We established prognostic metrics of ischemic stroke from 20 potential biomarkers in a propensity-score-matched extreme case sample (n = 146). Pathway analysis was conducted using Ingenuity Pathway Analysis. In the whole CATIS population (n = 3575), we evaluated effectiveness of these prognostic metrics and estimated their population-attributable fractions (PAFs) related to the risk of clinical outcomes. The primary outcome was a composite outcome of death or major disability (modified Rankin Scale score ≥3) at 3 months after stroke.

RESULTS

Matrix metalloproteinase-9 (MMP-9), S100A8/A9, high-sensitivity C-reactive protein (hsCRP), and growth differentiation factor-15 (GDF-15) were selected as prognostic metrics for ischemic stroke. Pathway analysis showed significant enrichment in inflammation and atherosclerosis signaling. All 4 prognostic metrics were independently associated with poor prognosis of ischemic stroke. Compared with patients having 1 or 0 high-level prognostic metrics, those with 4 had higher risk of primary outcome (OR: 3.84, 95%CI: 2.67-5.51; PAF: 37.4%, 95%CI: 19.5%-52.9%).

CONCLUSION

The set of prognostic metrics, enriching in inflammation and atherosclerosis signaling, could effectively predict the prognosis at 3 months after ischemic stroke and would provide additional information for the burden of adverse clinical outcomes among patients with ischemic stroke.

Blood Biomarkers to Predict Long-Term Mortality after Ischemic Stroke

Stroke is a major cause of disability and death globally, and prediction of mortality represents a crucial challenge. We aimed to identify blood biomarkers measured during acute ischemic stroke that could predict long-term mortality. Nine hundred and forty-one ischemic stroke patients were prospectively recruited in the Stroke-Chip study. Post-stroke mortality was evaluated during a median 4.8-year follow-up. A 14-biomarker panel was analyzed by immunoassays in blood samples obtained at hospital admission. Biomarkers were normalized and standardized using Z-scores. Multiple Cox regression models were used to identify clinical variables and biomarkers independently associated with long-term mortality and mortality due to stroke. In the multivariate analysis, the independent predictors of long-term mortality were age, female sex, hypertension, glycemia, and baseline National Institutes of Health Stroke Scale (NIHSS) score. Independent blood biomarkers predictive of long-term mortality were endostatin > quartile 2, tumor necrosis factor receptor-1 (TNF-R1) > quartile 2, and interleukin (IL)-6 > quartile 2. The risk of mortality when these three biomarkers were combined increased up to 69%. The addition of the biomarkers to clinical predictors improved the discrimination (integrative discriminative improvement (IDI) 0.022 (0.007–0.048), p < 0.001). Moreover, endostatin > quartile 3 was an independent predictor of mortality due to stroke. Altogether, endostatin, TNF-R1, and IL-6 circulating levels may aid in long-term mortality prediction after stroke.

Acute Stroke Biomarkers: Are We There Yet?

Background: Distinguishing between stroke subtypes and knowing the time of stroke onset are critical in clinical practice. Thrombolysis and thrombectomy are very effective treatments in selected patients with acute ischemic stroke. Neuroimaging helps decide who should be treated and how they should be treated but is expensive, not always available and can have contraindications. These limitations contribute to the under use of these reperfusion therapies.

Aim: An alternative approach in acute stroke diagnosis is to identify blood biomarkers which reflect the body's response to the damage caused by the different types of stroke. Specific blood biomarkers capable of differentiating ischemic from hemorrhagic stroke and mimics, identifying large vessel occlusion and capable of predicting stroke onset time would expedite diagnosis and increase eligibility for reperfusion therapies.

Summary of Review: To date, measurements of candidate biomarkers have usually occurred beyond the time window for thrombolysis. Nevertheless, some candidate markers of brain tissue damage, particularly the highly abundant glial structural proteins like GFAP and S100β and the matrix protein MMP-9 offer promising results. Grouping of biomarkers in panels can offer additional specificity and sensitivity for ischemic stroke diagnosis. Unbiased “omics” approaches have great potential for biomarker identification because of greater gene, protein, and metabolite coverage but seem unlikely to be the detection methodology of choice because of their inherent cost.

Conclusion: To date, despite the evolution of the techniques used in their evaluation, no individual candidate or multimarker panel has proven to have adequate performance for use in an acute clinical setting where decisions about an individual patient are being made. Timing of biomarker measurement, particularly early when decision making is most important, requires urgent and systematic study.

Extremely Low Serum Alanine Transaminase Level Is Associated with All-Cause Mortality in the Elderly after Intracranial Hemorrhage

OBJECTIVE

Extremely low alanine transaminase (ALT) levels are associated with all-cause mortality in frail elderly individuals; the clinical significance of ALT as a reliable biomarker is now being considered. Predicting mortality with routine tests at the time of diagnosis is important for managing patients after intracranial hemorrhage. We aimed to investigate whether an extremely low ALT level is associated with mortality in the elderly after intracranial hemorrhage.

METHODS

A retrospective review was performed on 455 patients with intracranial hemorrhage admitted to a university-affiliated tertiary care hospital from February 2014 to May 2019. Multivariate Cox regression analysis was performed for all ages and for each age group to determine whether an extremely low ALT level is an independent predictor of mortality only in the elderly.

RESULTS

Overall, 294 patients were enrolled, and the mean age of the subjects was 59.1 years, with 99 (33.8%) aged ≥65 years. The variables associated with all-cause mortality in all subjects were age, C-reactive protein (CRP) levels, hemoglobin (Hb) levels (<11 g/dL), and initial Glasgow coma scale (GCS) scores. In young patients, CRP, low Hb levels, and initial GCS scores were significantly associated with all-cause mortality. However, in the elderly (≥65 years), the variables significantly associated with allcause mortality were extremely low levels of ALT (<10 U/L) (adjusted hazard ratio, 3.313; 95% confidence interval, 1.232-8.909; p=0.018) and initial GCS scores.

CONCLUSION

Extremely low ALT level (<10 U/L) at the time of diagnosis is a significant risk factor for all-cause mortality in the elderly after intracranial hemorrhage.

Ischemia-modified albumin and fibulin-5 as diagnostic and prognostic markers for acute cerebrovascular disease

Background

Fibulin-5 and ischemia-modified albumin (IMA) levels increase in acute phase of cerebrovascular diseases, yet data regarding their levels in various stroke subtypes and correlation with severity and prognosis are still insufficient. This work aims to evaluate serum IMA and fibulin-5 as markers for early detection and predicting prognosis in acute cerebrovascular disease.

Method

This case-control study was done on 100 patients with first time stroke, assessed by the National Institute of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) within the first 24 h after stroke event, lesion volume was calculated, serum fibulin-5 and IMA levels were measured in the first few hours of stroke, and their levels were compared with levels measured in 75 control subjects. Three months later, stroke patients were assessed by the modified Rankin Scale (MRS).

Results

Fibulin-5 and IMA were significantly higher in the patient than in the control group and were positively correlated with lesion volume and NIHSS score but inversely correlated with GCS score. Fibulin-5 was statistically higher in hemorrhage group, whereas IMA was statistically higher in infarction group. MRS score was positively correlated with fibulin-5 levels at onset of stroke but not with IMA.

Conclusion

Fibulin-5 and ischemia-modified albumin are increased during the acute stroke phase and correlated with severity of stroke, but only fibulin-5 shows significant correlation with prognosis.

Role of Blood-Based Biomarkers in Ischemic Stroke Prognosis: A Systematic Review

BACKGROUND AND PURPOSE

Outcome prognostication in ischemic stroke patients remains challenging due to limited predictive properties of existing models. Blood-based biomarkers might provide additional information to established prognostic factors. We intended to identify the most promising prognostic biomarkers in ischemic stroke, their incremental prognostic value, and whether their predictive value differs among etiologies.

METHODS

We searched MEDLINE (Ovid) and Institute for Scientific Information Web of Knowledge for articles reporting the predictive performance of blood-based biomarkers measured up to 7 days after ischemic stroke and reporting functional outcome or death at least 7 days after stroke. This work updates a previous systematic review (up to January 2007), follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and was registered (International Prospective Register of Systematic Reviews PROSPERO 2018; https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018094671).

RESULTS

Two hundred ninety-one articles published between January 2007 and August 2018 comprising 257 different biomarkers met inclusion criteria. Median sample size was 232 (interquartile range, 110-455); 260 (89%) articles reported regression analyses with 78% adjusting for stroke severity, 82% for age, 67% for both, and 9% for none of them; 37% investigated discrimination, 5% calibration, and 11% reclassification. Including publications from a previous systematic review (1960-January 2007), natriuretic peptides, copeptin, procalcitonin, mannose-binding lectin, adipocyte fatty acid-binding protein, and cortisol were the biomarkers most consistently associated with poor outcome in higher-quality studies showing an incremental value over established prognostic factors. Other biomarkers were less consistently associated with poor outcome or were reported in lower quality studies. High heterogeneity among studies precluded the performance of a meta-analysis.

CONCLUSIONS

The number of reports on prognostic blood-based biomarkers in ischemic stroke increased 3.5-fold in the period January 2007 to August 2018. Although sample size increased, methodological flaws are still common. Natriuretic peptides and markers of inflammation, atherogenesis, and stress response are the most promising prognostic biomarkers among identified studies.

D-dimer Level is Correlated with Prognosis, Infarct Size, and NIHSS in Acute Ischemic Stroke Patients. Indian J Crit Care Med 2021;25:193-198. [PMID: 33707899 PMCID: PMC7922437 DOI: 10.5005/jp-journals-10071-23744]

Stroke ranks the fourth leading disease causing adult mortality and disability. D-dimer (D-D) is the ultimate product of plasmin-mediated degradation of fibrin-rich thrombi. D-D is a simple readily accessible biomarker employed within the diagnostic algorithms for the exclusion of venous thromboembolism. The correlation between D-D infarct size in MRI brain, APACHE II score, and the National Institute of Health Stroke Scale (NIHSS) score in critically ill acute stroke patients has not been fully investigated before.

Objective

We aimed to investigate the diagnostic and prognostic value of elevated plasma D-D in critically ill patients admitted with acute cerebrovascular accidents. As far as we know, we are the first to investigate the correlation between plasma D-D levels and the ischemic lesion size in MRI brain and also APACHE II score and NIHSS in critically ill acute ischemic cerebrovascular patients.

Setting and participants

A prospective, observational cohort study inside the Critical Care Medicine Department. Thirty patients with AIS were enrolled additionally to 1 healthy age- and sex-matched controls.

Interventions

We employed particle-enhanced, immunoturbidimetric assay to detect plasma D-D concentrations. D-D levels D0 and D1 were measured upon admission and 24 hours later, respectively. We reviewed the patient' s health records; additionally, demographic, clinical, laboratory, and neuroimaging information was abstracted.

Results

D-D concentrations were significantly higher in acute stroke patients compared to healthy controls. ROC curve analysis showed that elevated D-D level more than 310 ng/mL can predict infarct lesion size >1.5 cm in diffusion-weighted MRI brain with sensitivity and specificity (100 and 83%, respectively) and also admission D-D (D0) at cutoff concentration 350 ng/mL and D1 at cutoff value 370 ng/mL are predictors of complicated course with sensitivity and specificity (100 and 84.6%, respectively). There was no significant difference between D0 and D1 D-D levels (p-value >0.05).

Conclusion

The plasma D-D biomarker can be a simple readily available test reliable predictor of infarct lesion size >1.5 cm in DW-MRI and outcome in union with the common practice instrumental tests.

How to cite this article

Abbas NI, Sayed O, Samir S, Abeed N. D-dimer Level is Correlated with Prognosis, Infarct Size, and NIHSS in Acute Ischemic Stroke Patients. Indian J Crit Care Med 2021;25(2):193-198.

Can baseline C-reactive protein level predict functional outcome in acute ischaemic stroke? A meta-analysis

BACKGROUND

The association between elevated C-reactive protein (CRP) level and poor functional outcome is conflicting in acute ischaemic stroke (AIS) patients. This meta-analysis sought to investigate the value of elevated CRP level in predicting poor functional outcome in AIS patients.

MATERIAL AND METHODS

A systematically literature search was performed in PubMed and Embase databases up to 31 October 2019. Prospective and retrospective studies evaluating the association between elevated CRP level and poor functional outcome (defined by the modified Rankin scale ≥3) beyond 3 months after AIS were included.

RESULTS

Ten studies with a total of 8087 AIS patients were identified in this meta-analysis. When compared with reference low CRP level, the highest CRP level was associated with an increased risk of poor functional outcome (multivariate-adjusted hazard ratio (HR) 1.99; 95% confidence interval (CI) 1.63-2.44) in a random effect model. Sensitivity analysis further confirmed the significance of CRP elevation for predicting poor functional outcome after AIS.

CONCLUSIONS

Elevated CRP level is significantly associated with poor functional outcome in patients with AIS. Baseline CRP level has potential to improve risk stratification of function outcome in AIS patients.

Effect of IL-6 and hsCRP Serum Levels on Functional Prognosis in Stroke Patients Undergoing IV-Thrombolysis: Retrospective Analysis

Purpose

We evaluated the relationship between pretreatment IL-6 and hsCRP levels, symptom severity and functional outcome of patients with acute ischemic stroke (AIS) treated with IV-thrombolysis.

Patients and Methods

IL-6 and hsCRP samples were obtained from 83 consecutively treated Caucasian patients with AIS prior to initiation of IV-thrombolysis. Severity of stroke symptoms was assessed using the National Institutes of Health Stroke Scale (NIHSS), whereas functional outcome was assessed with modified Rankin Scale (mRS). The commercially available sets of enzymatic immune tests were used to estimate the concentrations of inflammatory markers in serum.

Results

Medians of IL-6 serum concentrations prior to IV-thrombolysis were lower in patients with favorable (mRS 0-2 pts) functional outcome than in those with unfavorable (mRS 3-6 pts) functional outcome, both at hospital dismission (5.92: 2.30-7.71 vs 9.46: 3.79-17.29 pg/mL; p<0.01) and on the ninetieth day from stroke onset (5.87: 2.30-10.58 vs 10.9: 5.94-17.28 pg/mL; p<0.01). There were no existing differences regarding hsCRP levels between groups (2.49: 0.11-9.82 vs 4.44: 0.32-9.87 mg/dL; p=0.30 and 2.57: 0.11-2.57 vs 2.83: 0.32-9.32 mg/dL; p=0.75, respectively). Patients with lacunar strokes were characterized by lower median of IL-6 (5.96: 2.87-13.0% vs 7.29: 2.30-17.28; p=<0.02) and hsCRP (2.25: 0.11-9.82 vs 4.84: 0.35-9.87; p=0.01) than those with nonlacunar infarctions. Multivariate analysis showed an impact of IL-6 on mRS measured on hospital dismission and after three months, regardless of their initial NIHSS, presence of hemorrhagic transformation and type 2 diabetes. No impact of hsCRP, lacunar etiology and patients' age on functional outcome existed.

Conclusion

Regardless of the stroke etiology, pretreatment of IL-6, but not of hsCRP levels, may help to predict functional outcome after IV-thrombolysis independently of symptom severity and stroke complications.

Investigating the relationship between interleukin-6 serum levels and outcome in acute ischemic CVA

INTRODUCTION

Interleukin-6 (IL-6) is among the inflammatory mediators exhibiting elevated levels in ischemic stroke (IS) patients. The present study set out to evaluate the relationship between serum levels of interleukin-6 with long-term and at-hospital outcomes of acute ischemic stroke in patients hospitalized at Imam Khomeini Hospital, Urmia, Iran, from 2017 to 2018.

METHOD AND MATERIALS

This cross-sectional descriptive study enrolled 29 and 31 acute stroke patients for long-term and at-hospital observation, respectively. Evaluation of stroke severity was performed using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) on days 1, 5, and 90. Serum IL-6 level was measured via enzyme-linked immunosorbent assay (ELISA) on days one and five.

RESULTS

In the present cohort study, the following population were enrolled: for long-term evaluation, 11 (38%) men and 18 (63%) women with a mean age of 64.5 ± 14.9 years, and for at-hospital evaluation: 11 (37.5%) men and 20 (64.5%) with a mean age of 65.25 ± 14.37 years. A significant positive correlation was observed between IL-6 levels with NIHSS and mRS scores of the patients from time of admission until the end of the follow-up period (long-term: p < .001; at-hospital: 0.022).

CONCLUSION

The evidence from the present study suggests that IL-6 contributes to the determination of the severity of ischemic strokes and may be useful in predicting prognosis. However, larger scale studies are required to further establish these finds.

Association of neonatal inflammatory markers and perinatal stroke subtypes

OBJECTIVE

To examine the relationship between neonatal inflammatory cytokines and perinatal stroke using a systems biology approach analyzing serum and blood-spot cytokines from 47 patients.

METHODS

This was a population-based, controlled cohort study with prospective and retrospective case ascertainment. Participants were recruited through the Alberta Perinatal Stroke Project. Stroke was classified as neonatal arterial ischemic stroke (NAIS), arterial presumed perinatal ischemic stroke (APPIS), or periventricular venous infarction (PVI). Biosamples were stored blood spots (retrospective) and acute serum (prospective). Controls had comparable gestational and maternal ages. Sixty-five cytokines were measured (Luminex). Hierarchical clustering analysis was performed to create heat maps. The Fisher linear discriminant analysis was used to create projection models to determine discriminatory boundaries between stroke types and controls.

RESULTS

A total of 197 participants were analyzed (27 with NAIS, 8 with APPIS, 12 with PVI, 150 controls). Cytokines were quantifiable with quality control measures satisfied (standards testing, decay analysis). Linear discriminant analysis had high accuracy in using cytokine profiles to separate groups. Profiles in participants with PVI and controls were similar. NAIS separation was accurate (sensitivity 77%, specificity 97%). APPIS mapping was also distinguishable from NAIS (sensitivity 86%, specificity 99%). Classification tree analysis generated similar diagnostic accuracy.

CONCLUSIONS

Unique inflammatory biomarker signatures are associated with specific perinatal stroke diseases. Findings support an acquired pathophysiology and suggest the possibility that at-risk pregnancies might be identified to develop prevention strategies.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that differences in acute neonatal serum cytokine profiles can discriminate between patients with specific perinatal stroke diseases and controls.

Clinical Usefulness of Cell-Free DNA as a Prognostic Marker in Acute Ischemic Stroke

OBJECTIVE

Stroke has become the second most common cause of death. Several biomarkers have been detected in the peripheral blood from stroke patients, but none has found a place in clinical practice. Cell-free DNA (cf-DNA) liberated into the blood soon after the onset of stroke might be useful for assessing disease severity and prognosis.

STUDY DESIGN AND METHODS

A total of 54 patients presenting with ischemic stroke were recruited consecutively with the exclusion of patients having trauma, tumor, infections, and organ failure. The cf-DNA was extracted by circulating nucleic acid kit from Qiagen and measured by real-time quantitative polymerase chain reaction assay for β-globin gene. The primary outcome measure was poststroke modified Rankin scale Score at 3 months after the onset of symptoms.

RESULTS

Higher cf-DNA levels were associated with severity at the time of admission measured by National Institutes of Health Stroke Scale (P=0.003) and poor outcome as measured by modified Rankin scale 3-month scores (P=0.001). Therapeutic intervention in the form of a mechanical thrombectomy or IV thrombolysis was associated with improved outcome in patients with cf-DNA<10,000 kilogenome-equivalents/L (P≤0.01).

CONCLUSIONS

cf-DNA level correlates well with the severity of stroke at admission and long-term prognosis. It can be used as an additional marker to predict the outcome of therapeutic intervention.

Association between serum hepatocyte growth factor and prognosis of ischemic stroke: The role of blood lipid status

BACKGROUND AND AIMS

High serum hepatocyte growth factor (HGF) levels increase the risk of ischemic stroke and are probably associated with outcomes after ischemic stroke. However, it remains unclear whether the association between HGF and ischemic stroke prognosis is modified by blood lipid status.

METHODS AND RESULTS

Data were derived from the CATIS (China Antihypertensive Trial in Acute Ischemic Stroke), and we measured baseline serum HGF levels in 3027 ischemic stroke patients. The primary outcome was a combination of death and major disability (modified Rankin Scale score≥3) at 2 years after ischemic stroke. Blood lipid status could modify association between HGF and ischemic stroke prognosis (P_interaction = 0.002). After multivariate adjustment, the odds ratios of primary outcome associated with the highest tertile of HGF were 2.13 (95% CI, 1.45-3.14; P_trend<0.001) for patients with dyslipidemia and 0.81 (95% CI, 0.54-1.22; P_trend = 0.310) for those with normal lipids. Adding HGF to conventional risk factors improved risk prediction for primary outcome in patients with dyslipidemia (net reclassification improvement: 24.28%, P < 0.001; integrated discrimination index: 0.43%, P = 0.022) but not in those with normal lipids. Secondary analyses further revealed that HDL-C was the main lipid component to modify the prognostic significance of serum HGF among ischemic stroke patients.

CONCLUSIONS

There was a modified effect of blood lipid status on the association between serum HGF and ischemic stroke prognosis. Elevated serum HGF was associated with outcomes in ischemic stroke patients with dyslipidemia, especially low HDL-C. Further studies are warranted to replicate our findings and clarify the potential biological mechanisms.

Dynamic Changes and Prognostic Value of Gut Microbiota-Dependent Trimethylamine-N-Oxide in Acute Ischemic Stroke

Background: Acute ischemic stroke (AIS) is an atherothrombotic disease. Trimethylamine-N-oxide (TMAO), a gut microbiota-dependent metabolite, has been shown to be proatherogenic and prothrombotic. However, the involvement of TMAO in AIS remains unclear. This study aimed to observe the dynamic changes of TMAO in AIS patients and identify the prognostic value of TMAO for major ischemic events and unfavorable functional outcomes. Methods: This study included 204 AIS patients and 108 healthy controls. Blood samples for TMAO analyses were drawn at admission, 2 and 7 days of admission. Logistic regression models and receiver operating characteristic curves were established to identify associations between TMAO levels and major ischemic events (ischemic stroke, myocardial infarction, or death from an ischemic vascular event), as well as unfavorable functional outcomes (modified Rankin Scale score ≥3), at 90 days and 12 months. Results: TMAO levels showed no significant changes before and within 24 h of AIS treatment (at admission) but decreased significantly thereafter. Elevated log₂-transformed baseline TMAO levels were associated with increased risks of 90-day [odds ratio (OR), 2.62; 95% confidence interval (CI), 1.55-4.45; p < 0.001] and 12-month (OR, 3.59; 95% CI, 2.12-6.09; p < 0.001) major ischemic events, as well as 90-day (OR, 2.89; 95% CI, 1.46-5.71; p = 0.002) and 12-month (OR, 2.58; 95% CI, 1.50-4.46; p = 0.001) unfavorable functional outcomes, after adjustments for confounding factors. The areas under curve of baseline TMAO levels for predicting 90-day and 12-month major ischemic events were 0.72 (95% CI, 0.61-0.83; p < 0.001) and 0.76 (95% CI, 0.66-0.85; p < 0.001). Baseline TMAO levels improved the prognostic accuracy of conventional risk factors, National Institutes of Health Stroke Scale (NIHSS) score and N-terminal B-type natriuretic peptide (NT-proBNP) level. Conclusions: TMAO levels decreased with time since stroke onset. Elevated TMAO levels at an earlier period portended poor stroke outcomes, broadening the potential clinical utility of TMAO as an independent prognostic marker and therapeutic target.

Blood Biomarkers for Stroke Diagnosis and Management

Biomarkers are objective indicators used to assess normal or pathological processes, evaluate responses to treatment and predict outcomes. Many blood biomarkers already guide decision-making in clinical practice. In stroke, the number of candidate biomarkers is constantly increasing. These biomarkers include proteins, ribonucleic acids, lipids or metabolites. Although biomarkers have the potential to improve the diagnosis and the management of patients with stroke, there is currently no marker that has demonstrated sufficient sensitivity, specificity, rapidity, precision, and cost-effectiveness to be used in the routine management of stroke, thus highlighting the need for additional work. A better standardization of clinical, laboratory and statistical procedures between centers is indispensable to optimize biomarker performance. This review focuses on blood biomarkers that have shown promise for translation into clinical practice and describes some newly reported markers that could add to routine stroke care. Avenues for the discovery of new stroke biomarkers and future research are discussed. The description of the biomarkers is organized according to their expected application in clinical practice: diagnosis, treatment decision, and outcome prediction.

Leukocyte Count and Adverse Clinical Outcomes in Acute Ischemic Stroke Patients

Background: Post-ischemic inflammatory response might be affected by many factors. We chose leukocyte count as a marker of inflammatory response and investigated whether the effects of leukocyte count on the clinical outcomes in acute ischemic stroke patients are different according to different factors.

Methods: We derived data from the China National Stroke Registry II. Patients with ischemic stroke were classified into four groups by leukocyte count quartiles within the first 24 h after admission. Adverse clinical outcomes were defined as recurrent stroke, all-cause death, and poor functional outcomes (3 ≤ mRS ≤ 5) at 3-months and 1-year follow-up. The subgroup factors were age, sex, history of hypertension, history of diabetes, history of previous stroke, or transient ischemic attack and smoking status. We assessed the association between leukocyte count and adverse clinical outcomes and evaluated this association in different subgroups.

Results: A total of 14,678 patients were included. Patients in higher quartiles were likely to be younger, male, smokers, and drinkers, and to have a shorter time from symptom onset to arrival, a more proportion of history of diabetes, atrial fibrillation, and hypertension, and a higher severity of stroke. Higher quartiles were associated with elevated risk of adverse clinical outcomes at 3-months and 1-year follow-up. Leukocyte count had a moderate accuracy to predict clinical outcomes. There was no difference in the relationship between leukocyte count and adverse clinical outcomes across subgroups such as age, sex, history of hypertension, and smoking. The effect of leukocyte count on all-cause death was pronounced among patients with previous stroke or transient ischemic attack, and the effect of leukocyte count on short-term poor functional outcomes was also pronounced among patients without diabetes.

Conclusions: Leukocyte count is associated with short-term and long-term clinical outcomes of acute ischemic stroke and may have predictive value, especially in patients with certain specific characteristics.

Systematic review and REMARK scoring of renal cell carcinoma prognostic circulating biomarker manuscripts

Background

No validated molecular biomarkers exist to help guide prognosis of renal cell carcinoma (RCC) patients. We seek to evaluate the quality of published prognostic circulating RCC biomarker manuscripts using the Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK) guidelines.

Methods

The phrase “(renal cell carcinoma OR renal cancer OR kidney cancer OR kidney carcinoma) AND circulating AND (biomarkers OR cell free DNA OR tumor DNA OR methylated cell free DNA OR methylated tumor DNA)” was searched in Embase, Medline and PubMed March 2018. Relevant manuscripts were scored using 48 REMARK sub-criteria for a maximal score of 20 points.

Results

The search identified 535 publications: 33 were manuscripts of primary research and were analyzed. The mean REMARK score was 10.6 (range 6.42–14.2). All manuscripts stated their biomarker, study objectives and method of case selection. The lowest scoring criteria: time lapse between storage of blood/serum and marker assay (n = 2) and lack of flow diagram (n = 2). REMARK scores were significantly higher in publications stating adherence to REMARK guidelines (p = 0.0307) and reporting statistically significant results (p = 0.0318).

Conclusions

Most RCC prognostic biomarker manuscripts poorly adhere to the REMARK guidelines. Better designed studies and appropriate reporting are required to address this urgent unmet need.

Neutrophil to lymphocyte ratio predicts poor outcomes after acute ischemic stroke: A cohort study and systematic review

BACKGROUND AND PURPOSE

The relationship between neutrophil to lymphocyte ratio (NLR) and prognosis after acute ischemic stroke (AIS) remains controversial. The aim of this cohort study and systematic review was to ascertain the association of admission NLR with major clinical poor outcomes after AIS.

METHODS

We analyzed data from Chengdu stroke registry and performed a systematic review for previous literature. The outcomes were hemorrhagic transformation (HT), parenchymal hematoma (PH), symptomatic intracranial hemorrhage (sICH), 3-month death or disability (modified Rankin Scale≥3), and 3-month death. Odds ratios (ORs) and 95% confidence intervals (CIs) of NLR as a continuous and categorical variable and poor outcomes were pooled separately. We also calculated the predictive accuracy of admission NLR in different outcomes.

RESULTS

We included 808 patients from registry database and 9563 patients from previous studies. Our registry data showed that NLR ≥5 was associated with HT (OR 2.03, 95%CI 1.19-3.46), PH (OR 2.54, 95%CI 1.20-5.35) and 3-month death (OR 5.55, 95%CI 1.41-21.89); meta-analysis with our data and other observational studies indicated that higher NLR was associated with HT (OR 1.99, 95% CI 1.45-2.73), sICH (OR 2.22, 95% CI 1.60-3.09), 3-month death or disability (OR 1.68, 95% CI 1.18-2.38), and 3-month death (OR 2.79, 95% CI 1.57, 4.94). NLR had the highest predictive accuracy for 3-month death.

CONCLUSIONS

Higher NLR is positively associated with the risk of HT and 3-month death after stroke. Considering the limited predictive ability of a single biomarker, more studies should validate the role of NLR in prognostic models.