Inflammatory mechanisms of stroke

Role of transcription factors, noncoding RNAs, epitranscriptomics, and epigenetics in post-ischemic neuroinflammation

Post-stroke neuroinflammation is pivotal in brain repair, yet persistent inflammation can aggravate ischemic brain damage and hamper recovery. Following stroke, specific molecules released from brain cells attract and activate central and peripheral immune cells. These immune cells subsequently release diverse inflammatory molecules within the ischemic brain, initiating a sequence of events, including activation of transcription factors in different brain cell types that modulate gene expression and influence outcomes; the interactive action of various noncoding RNAs (ncRNAs) to regulate multiple biological processes including inflammation, epitranscriptomic RNA modification that controls RNA processing, stability, and translation; and epigenetic changes including DNA methylation, hydroxymethylation, and histone modifications crucial in managing the genic response to stroke. Interactions among these events further affect post-stroke inflammation and shape the depth of ischemic brain damage and functional outcomes. We highlighted these aspects of neuroinflammation in this review and postulate that deciphering these mechanisms is pivotal for identifying therapeutic targets to alleviate post-stroke dysfunction and enhance recovery.

The Role of High-Density Lipoprotein, C-reactive Protein, and Serum Ferritin in Ischemic and Hemorrhagic Stroke: An Observational Cross-Sectional Comparative Study

Background Stroke is a significant global health issue, with a high prevalence of morbidity, mortality, and disability. We can classify strokes into two types: ischemic and hemorrhagic, with ischemic strokes being more common. This study aims to investigate the role of high-density lipoprotein (HDL), C-reactive protein (CRP), and serum ferritin levels in people who have had ischemic and hemorrhagic strokes in order to identify possible biomarkers for diagnosis and treatment. Materials and methods This observational cross-sectional comparative study included 100 stroke patients (50 ischemic and 50 hemorrhagic) from Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune. We collected data through clinical evaluations, laboratory tests, and imaging studies. We measured and analyzed HDL, CRP, and serum ferritin levels using appropriate statistical tests, such as the chi-square test and Student t-test, with a 95% confidence interval (CI) and a 5% p-value for significance. Results The mean age for ischemic stroke patients was 55.92 years, whereas for hemorrhagic stroke patients, it was 58.68 years. The study found significant differences in HDL, CRP, and ferritin levels between the two groups. The mean HDL level for ischemic stroke patients was significantly lower at 25.10 mg/dL, compared to 40.57 mg/dL in hemorrhagic stroke patients, with a p-value of <0.001. The mean CRP level was higher in ischemic stroke patients (28.90 mg/L) compared to hemorrhagic stroke patients (22.80 mg/L), with a p-value of <0.001. Ferritin levels were also higher in hemorrhagic stroke patients (587.98 ng/mL) compared to ischemic stroke patients (473.16 ng/mL), with a statistically significant p-value of <0.001. Conclusion This study highlights the significant role of HDL, CRP, and serum ferritin levels in distinguishing between ischemic and hemorrhagic stroke patients. Elevated HDL levels may protect against ischemic strokes due to their anti-inflammatory properties, while higher CRP levels in ischemic strokes indicate a strong inflammatory response. Elevated ferritin levels in hemorrhagic strokes suggest increased oxidative stress and inflammation.

Systemic immune-inflammation index upon admission correlates to post-stroke cognitive impairment in patients with acute ischemic stroke

BACKGROUND

The purpose of this prospective study was to evaluate the association of systemic immune-inflammation index (SII) and systemic inflammation response index (SIRI), with PSCI in patients with acute ischemic stroke (AIS).

METHODS

First-onset AIS patients were consecutively included from January 1, 2022 to March 1, 2023. The baseline information was collected at admission. Fasting blood was drawn the next morning. Cognitive function was assessed by the Montreal Cognitive Assessment (MoCA) 3 months after onset. Logistic regression analysis was performed to explore the correlation between SII, SIRI, and PSCI. Receiver operating characteristic (ROC) was conducted to evaluate the predictive ability of SII.

RESULTS

332 participants were recruited, and 193 developed PSCI. Compared with patients without PSCI, the patients with PSCI had higher SII (587.75 (337.42, 988.95) vs. 345.66 (248.44, 572.89), P<0.001) and SIRI (1.59 (0.95, 2.84) vs. 1.02 (0.63, 1.55), P=0.007). SII and SIRI negatively correlated with MoCA scores (both P<0.05). The multivariable logistic regression analysis indicated that SII was independently associated with PSCI (P<0.001), while SIRI was not. The optimal cutoff for SII to predict PSCI was 676.83×109/L.

CONCLUSIONS

A higher level of SII upon admission was independently correlated to PSCI three months later in AIS patients.

Pericarotid adipose tissue computed tomography attenuation distinguishes different stages of carotid atherosclerotic disease: a cross-sectional study

Background

Carotid atherosclerotic plaque inflammation plays a critical role in guiding the prevention of secondary stroke. Increased perivascular adipose tissue attenuation observed on computed tomography angiography (CTA) may indicate local inflammation. Our objective was to investigate whether pericarotid adipose tissue (PCAT), as a local inflammation biomarker, could distinguish between different stages of carotid atherosclerotic disease plaques.

Methods

We prospectively enrolled 45 consecutive acute stroke patients with carotid artery stenosis from September 2019 to September 2021. We then matched them to non-stroke patients (n=67) and no carotid atherosclerotic disease controls (n=65) based on gender, age, and cardiovascular risk factors. We compared PCAT attenuation, carotid plaque features on CTA, clinical risk factors, and serum inflammatory factors across the different groups. To detect the association of PCAT attenuation with stage of carotid atherosclerotic disease, we used multivariable logistic regression analysis.

Results

Patients with acute stroke had a higher PCAT attenuation (-78.80±11.62 HU) than patients with non-stroke (-89.01±10.81 HU, P<0.001) and no carotid atherosclerotic disease controls (-95.24±10.81 HU, P<0.001). PCAT attenuation was significantly increased in non-stroke patients compared to non-stroke patients over no carotid atherosclerotic disease controls (P=0.004). The association between PCAT attenuation and the stage of carotid atherosclerotic disease was independent of age, gender, cardiovascular risk factors, and CTA plaque characteristics. No interaction was observed between clinical features and CTA plaque characteristics on PCAT attenuation.

Conclusions

PCAT attenuation, which is an imaging biomarker of local inflammation, independently distinguishes patients with different stages of carotid atherosclerotic disease. Quantitative evaluation of PCAT attenuation in carotid atherosclerotic disease is expected to guide targeted surgical treatment of carotid plaque.

Systematic Mendelian randomization using the human plasma proteome to discover potential therapeutic targets for stroke

Stroke is the second leading cause of death with substantial unmet therapeutic needs. To identify potential stroke therapeutic targets, we estimate the causal effects of 308 plasma proteins on stroke outcomes in a two-sample Mendelian randomization framework and assess mediation effects by stroke risk factors. We find associations between genetically predicted plasma levels of six proteins and stroke (P ≤ 1.62 × 10-4). The genetic associations with stroke colocalize (Posterior Probability >0.7) with the genetic associations of four proteins (TFPI, TMPRSS5, CD6, CD40). Mendelian randomization supports atrial fibrillation, body mass index, smoking, blood pressure, white matter hyperintensities and type 2 diabetes as stroke risk factors (P ≤ 0.0071). Body mass index, white matter hyperintensity and atrial fibrillation appear to mediate the TFPI, IL6RA, TMPRSS5 associations with stroke. Furthermore, thirty-six proteins are associated with one or more of these risk factors using Mendelian randomization. Our results highlight causal pathways and potential therapeutic targets for stroke.

High neutrophil percentage and neutrophil-lymphocyte ratio in acute phase of ischemic stroke predict cognitive impairment: A single-center retrospective study in China

Background and aims

Recently, various hemocyte and blood cell ratios have garnered researchers' attention, as a low-cost, widely prevalent, and easy-to-measure index for diagnosing and predicting disease. Therefore, we sought to investigate the effect and predictive value of the peripheral blood neutrophil percentage and neutrophil-lymphocyte ratio (NLR) in the acute phase of ischemic stroke (AIS) in post-stroke cognitive impairment (PSCI).

Methods

We selected 454 patients with mild AIS and acquired general clinical data. The patients were divided into PSCI and post-stroke no cognitive impairment (PSNCI) groups according to their Montreal Cognitive Assessment (MOCA) scores. We assessed whether there were differences in clinical data, peripheral blood neutrophil percentage, and NLR values between the different groups. We also analyzed the independent influences on the occurrence of PSCI using a binary logistic regression. Receiver operating characteristic (ROC) curves were used to analyze the predictive value of the above inflammatory indicators and models containing different inflammatory indicators for PSCI.

Results

In total, 454 patients were included, of whom 253 (55.7%) patients were in the PSCI group, with a mean age of 62.15 ± 7.34 years and median neutrophil percentage and NLR of 0.64 (0.32–0.95) and 2.39 (0.71–54.46), respectively. Both neutrophil percentage (adjusted OR = 1.025; 95% confidence interval: 1.005–1.406) and NLR as a categorical variable (Q5, adjusted OR = 2.167; 95% CI: 1.127–4.166) were independent risk factors for PSCI, and the Q5 group (NLR ≥ 4.05) had significantly worse overall cognition and executive function.

Conclusions

Neutrophil percentage and NLR in the acute phase of AIS were independently associated with PSCI, and a high NLR was strongly associated with executive function. In addition, neutrophil percentage and NLR have diagnostic values for PSCI.

Lipidomics Revealed Aberrant Lipid Metabolism Caused by Inflammation in Cardiac Tissue in the Early Stage of Systemic Lupus Erythematosus in a Murine Model

Cardiac involvement, displayed as premature cardiovascular disease (CVD), is one of common clinical symptoms of patients with systemic lupus erythematosus (SLE), contributing to mortality of the disease. The precise underlying pathological mechanism(s) for the cardiac involvement in lupus remains poorly understood. Lipids and their metabolites are directly involved in atherosclerosis development, oxidative stress, and inflammation, which are closely related to the development of CVD. In the study, shotgun lipidomics was exploited to quantitatively analyze cellular lipidomes in the cardiac tissue of MRL/lpr mice at two different time points (i.e., pre-lupus and lupus state) with/without treatment with glucocorticoids (GCs). Urine protein, spleen index, and renal histopathological evaluation of the mice were also performed for assessment of SLE onset and/or outcome. Lipidomics analysis revealed that the deposition of cholesterol and the aberrant metabolism of lipids caused by the increased energy metabolism and the enhanced activation of phospholipases, both of which were originally induced by inflammation, were already present in cardiac tissues from lupus-prone mice even at pre-lupus state. These lipid alterations could further induce inflammation and autoimmune responses, accelerating the process of CVD. In addition, the present study also demonstrated that GCs therapy could not only delay the progression of SLE, but also partially corrected these alterations of lipid species in cardiac tissue due to their anti-inflammatory effect. Thus, the medications with better anti-inflammatory effect might be a useful therapeutic method for premature CVD of SLE.

Association of Socioeconomic Status and Infarct Volume With Functional Outcome in Patients With Ischemic Stroke

IMPORTANCE

Long-term disability after stroke is associated with socioeconomic status (SES). However, the reasons for such disparities in outcomes remain unclear.

OBJECTIVE

To assess whether lower SES is associated with larger admission infarct volume and whether initial infarct volume accounts for the association between SES and long-term disability.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted in a prospective, consecutive population (n = 1256) presenting with acute ischemic stroke who underwent magnetic resonance imaging (MRI) within 24 hours of admission. Patients were recruited in Massachusetts General Hospital, Boston, from May 31, 2009, to December 31, 2011. Data were analyzed from May 1, 2019, until June 30, 2020.

MAIN OUTCOMES AND MEASURES

Initial stroke severity (within 24 hours of presentation) was determined using clinical (National Institutes of Health Stroke Scale [NIHSS]) and imaging (infarct volume by diffusion-weighted MRI) measures. Stroke etiologic subtypes were determined using the Causative Classification of Ischemic Stroke algorithm. Long-term stroke disability was measured using the modified Rankin Scale. Socioeconomic status was estimated using zip code-derived median household income and census block group-derived area deprivation index (ADI). Regression and mediation analyses were performed.

RESULTS

A total of 1098 patients had imaging and SES data available (mean [SD] age, 68.1 [15.7] years; 607 men [55.3%]). Income was inversely associated with initial infarct volume (standardized β, -0.074 [95% CI, -0.127 to -0.020]; P = .007), initial NIHSS (standardized β, -0.113 [95% CI, -0.171 to -0.054]; P < .001), and long-term disability (standardized β, -0.092 [95% CI, -0.149 to -0.035]; P = .001), which remained significant after multivariable adjustments. Initial stroke severity accounted for 64% of the association between SES and long-term disability (standardized β, -0.063 [95% CI, -0.095 to -0.029]; P < .05). Findings were similar when SES was alternatively assessed using ADI.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that lower SES is associated with larger infarct volumes on presentation. These SES-associated differences in initial stroke severity accounted for most of the subsequent disparities in long-term disability in this study. These findings shift the culpability for SES-associated disparities in poststroke disability from poststroke factors to those that precede presentation.

A J-Shaped Curve Relationship Between Baseline Fasting Blood Glucose and 1-Year Stroke Recurrence in Non-diabetic Patients With Acute Cerebral Infarction in Xi'an, China: A Multicenter Observational Cohort Study

Background

The relationship between baseline fasting blood glucose (FBG) levels and 1-year stroke recurrence in non-diabetic patients with acute cerebral infarction (ACI) is unclear. We aimed to clarify this relationship in non-diabetic patients with ACI.

Methods

Baseline FBG levels and related information of the patients were collected at admission and the events of stroke recurrence were followed up 1, 3, 6, and 12 months after the patients were discharged. Baseline FBG levels were analyzed as continuous variables and quartiles (Q1–Q4). Multivariate Cox regression models and a two-piecewise linear regression model were used to investigate the relationship and determine the threshold effect between baseline FBG levels and 1-year stroke recurrence in non-diabetic patients with ACI.

Results

Overall, 1,634 non-diabetic patients with ACI were enrolled. After adjusting for potential confounding factors, the hazard is 2.24-fold higher in Q4 than those in Q2, being considered the reference in non-diabetic patients with ACI [hazard ratio (HR) = 2.24, 95%CI: 1.08–4.65, P = 0.031]. Plotting hazard ratios over baseline FBG levels suggested a J-shaped relationship for 1-year stroke recurrence. Further analysis revealed that the nadir value of baseline FBG levels is 4.6 mmol/L. The relationship was more significant in patients with atrial fibrillation than in those without (P for interaction = 0.009).

Conclusion

Lower and higher baseline FBG levels may lead to an increased risk of 1-year stroke recurrence in non-diabetic patients with ACI as shown by a J-shaped curve with a nadir value of 4.6 mmol/L.

Ιmmunity, Vascular Aging, and Stroke

Stroke is one of the most devastating manifestations of cardiovascular disease. Growing age, arterial hypertension, and atherosclerosis are identified as independent risk factors for stroke, primarily due to structural and functional alterations in the cerebrovascular tree. Recent data from in vitro and clinical studies have suggested that the immune system influences atherosclerosis, promoting vascular stiffness and vascular aging and contributing to ischemic stroke, intracranial haemorrhage and microbleeds, white matter disease, and cognitive decline. Furthermore, aging is related to a chronic low-grade inflammatory state, in which macrophage, neutrophils, natural killer (NK cells), and B and T lymphocytes act as major effectors of the immune-mediated cell responses. Moreover, oxidative stress and vascular inflammation are correlated with endothelial dysfunction, vascular aging, blood-brain barrier disruption, lacunar lesions, and neurodegenerative disorders. This review discusses the pathophysiological roles of fundamental cellular and molecular mechanisms of aging, including the complex interplay between them and innate immunity, as well as vascular dysfunction, arterial stiffness, atherosclerosis, atherothrombosis, systemic inflammation, and blood-brain barrier dysfunction.

Clinical Features and Prognostic Factors of Acute Ischemic Stroke Related to Malignant Gastrointestinal Tumor

Objectives: To analyze the clinical and imaging features of acute ischemic stroke (AIS) related to gastrointestinal malignant tumor, and to explore the prognostic factors.

Methods: Clinical data of consecutive patients with gastrointestinal malignant tumor complicated with AIS admitted to the Department of Neurology and Oncology in Lanzhou University Second Hospital from April 2015 to April 2019 were retrospectively analyzed. Patients were divided into good prognosis (mRS 0–2) and poor prognosis (mRS > 2) based on a 90-day mRS score after discharge. The multivariate logistic regression model was used to analyze the prognostic factors.

Results: A total of 68 patients were enrolled with an average age of 61.78 ± 6.65 years, including 49 men (72.06%). There were 18 patients in the good prognosis group and 50 patients in the poor prognosis group. The univariate analysis showed that Hcy, D-dimer, thrombin–antithrombin complex (TAT), and three territory sign in magnetic resonance imaging (MRI) were the risk factors for poor prognosis. Multivariate analysis showed that increased D-dimer (OR 4.497, 95% CI 1.014–19.938) and TAT levels (OR 4.294, 95% CI 1.654–11.149) were independent risk factors for the prognosis in such patients.

Conclusion: Image of patients with gastrointestinal malignant tumor-related AIS is characterized by three territory sign (multiple lesions in different vascular supply areas). Increased TAT and D-dimer levels are independent prognostic risk factors. TAT is more sensitive to predict prognosis than D-dimer.

Trimeric chalchonoids from the total phenolic extract of Chinese dragon's blood (the red resin of Dracaena cochinchinensis)

Four new chalchonoid trimers, named cochinchinenins N-Q (1-4), along with a pair of known enantiomers (5-6), were isolated from the total phenolic extract of Chinese dragon's blood (the red resin of Dracaena cochinchinensis). The planar structures of 1-4 were elucidated by extensive spectroscopic analysis including HRESIMS and 1D/2D NMR. The absolute configurations of new compounds were established by ECD data. Compound 1 exhibited significant inhibition of nitric oxide production in lipopolysaccharide-stimulated BV-2 microglial cells with IC₅₀ value of 11.5 ± 1.7 μM.

Dose-Dependent Association of Inflammatory Cytokines with Carotid Atherosclerosis in Transient Ischaemic Attack: Implications for Clinical Trials

INTRODUCTION

The 5-year recurrence risk after ischaemic stroke and transient ischaemic attack (TIA) is 25-30%. Although inflammation may be a target for prevention trials, the contribution of plaque inflammation to acute cerebrovascular events remains unclear. We investigated the association of acute inflammatory cytokines and high-sensitivity C-reactive protein (CRP) with recently symptomatic carotid atherosclerosis in a prospective cohort study.

METHODS

Blood and Imaging markers of TIA BIO-TIA) is a multicentre prospective study of imaging and inflammatory markers in patients with TIA. Exclusion criteria were infection and other co-morbid illnesses associated with inflammation. CRP and serum cytokines (interleukin [IL]-6, IL-1β, IL-8, IL-10, IL-12, interferon-γ [IFN-γ] and tumour necrosis factor-α [TNF-α]) were measured. All patients had carotid imaging.

RESULTS

Two hundred and thirty-eight TIA cases and 64 controls (TIA mimics) were included. Forty-nine (20.6%) cases had symptomatic internal carotid artery stenosis. Pro-inflammatory cytokine levels increased in a dose-dependent manner across controls, TIA without carotid stenosis (CS), and TIA with CS (IL-1β, ptrend = 0.03; IL-6, ptrend < 0.0001; IL-8, ptrend = 0.01; interferon (IFN)-γ, ptrend = 0.005; TNF-α, ptrend = 0.003). Results were unchanged when DWI-positive cases were excluded. On multivariable linear regression, only age (p = 0.01) and CS (p = 0.04) independently predicted log-IL-6. On multivariable Cox regression, CRP was the only independent predictor of 90-day stroke recurrence (adjusted hazard ratio per 1-unit increase 1.03 [95% CI: 1.01-1.05], p = 0.003).

CONCLUSION

Symptomatic carotid atherosclerosis was associated with elevated cytokines in TIA patients after controlling for other sources of inflammation. High-sensitivity CRP was associated with recurrent ischaemic stroke at 90 days. These findings implicate acute plaque inflammation in the pathogenesis of cerebral thromboembolism and support a rationale for randomized trials of anti-inflammatory therapy for stroke patients, who were excluded from coronary trials.

The pleiotropic effects of antithrombotic drugs in the metabolic-cardiovascular-neurodegenerative disease continuum: impact beyond reduced clotting

Antithrombotic drugs are widely used for primary and secondary prevention, as well as treatment of many cardiovascular disorders. Over the past few decades, major advances in the pharmacology of these agents have been made with the introduction of new drug classes as novel therapeutic options. Accumulating evidence indicates that the beneficial outcomes of some of these antithrombotic agents are not solely related to their ability to reduce thrombosis. Here, we review the evidence supporting established and potential pleiotropic effects of four novel classes of antithrombotic drugs, adenosine diphosphate (ADP) P2Y12-receptor antagonists, Glycoprotein IIb/IIIa receptor Inhibitors, and Direct Oral Anticoagulants (DOACs), which include Direct Factor Xa (FXa) and Direct Thrombin Inhibitors. Specifically, we discuss the molecular evidence supporting such pleiotropic effects in the context of cardiovascular disease (CVD) including endothelial dysfunction (ED), atherosclerosis, cardiac injury, stroke, and arrhythmia. Importantly, we highlight the role of DOACs in mitigating metabolic dysfunction-associated cardiovascular derangements. We also postulate that DOACs modulate perivascular adipose tissue inflammation and thus, may reverse cardiovascular dysfunction early in the course of the metabolic syndrome. In this regard, we argue that some antithrombotic agents can reverse the neurovascular damage in Alzheimer's and Parkinson's brain and following traumatic brain injury (TBI). Overall, we attempt to provide an up-to-date comprehensive review of the less-recognized, beneficial molecular aspects of antithrombotic therapy beyond reduced thrombus formation. We also make a solid argument for the need of further mechanistic analysis of the pleiotropic effects of antithrombotic drugs in the future.

Sestrin2 regulates microglia polarization through mTOR-mediated autophagic flux to attenuate inflammation during experimental brain ischemia

Background

Neuroinflammation is the major pathogenesis of cerebral ischemia. Microglia are activated and polarized to either the pro-inflammatory M1 phenotype or anti-inflammatory M2 phenotype, which act as a critical mediator of neuroinflammation. Sestrin2 has pro-survival properties against ischemic brain injury. However, whether sestrin2 has an anti-inflammatory function by shifting microglia polarization and its underlying mechanism is unknown.

Methods

Adult male C57BL/6 mice (N = 108) underwent transient middle cerebral artery occlusion (tMCAO) and were treated with exogenous sestrin2. Neurological deficit scores and infarct volume were determined. Cell apoptosis was examined by TUNEL staining and Western blotting. The expression of inflammatory mediators, M1/M2-specific markers, and signaling pathways were detected by reverse transcription-polymerase chain reaction, immunostaining, and Western blotting. To explore the underlying mechanism, primary neurons were subjected to oxygen-glucose deprivation (OGD) and then treated with oxygenated condition medium of BV2 cells incubated with different doses of sestrin2.

Results

Sestrin2 attenuated the neurological deficits, infarction volume, and cell apoptosis after tMCAO compared to those in the control (p < 0.05). Sestrin2 had an anti-inflammatory effect and could suppress M1 microglia polarization and promote M2 microglia polarization. Condition medium from BV2 cells cultured with sestrin2 reduced neuronal apoptosis after OGD in vitro. Furthermore, we demonstrated that sestrin2 drives microglia to the M2 phenotype by inhibiting the mammalian target of rapamycin (mTOR) signaling pathway and restoring autophagic flux.

Conclusions

Sestrin2 exhibited neuroprotection by shifting microglia polarization from the M1 to M2 phenotype in ischemic mouse brain, which may be due to suppression of the mTOR signaling pathway and the restoration of autophagic flux.

The Neat Dance of COVID-19: NEAT1, DANCR, and Co-Modulated Cholinergic RNAs Link to Inflammation

The COVID-19 pandemic exerts inflammation-related parasympathetic complications and post-infection manifestations with major inter-individual variability. To seek the corresponding transcriptomic origins for the impact of COVID-19 infection and its aftermath consequences, we sought the relevance of long and short non-coding RNAs (ncRNAs) for susceptibility to COVID-19 infection. We selected inflammation-prone men and women of diverse ages among the cohort of Genome Tissue expression (GTEx) by mining RNA-seq datasets from their lung, and blood tissues, followed by quantitative qRT-PCR, bioinformatics-based network analyses and thorough statistics compared to brain cell culture and infection tests with COVID-19 and H1N1 viruses. In lung tissues from 57 inflammation-prone, but not other GTEx donors, we discovered sharp declines of the lung pathology-associated ncRNA DANCR and the nuclear paraspeckles forming neuroprotective ncRNA NEAT1. Accompanying increases in the acetylcholine-regulating transcripts capable of controlling inflammation co-appeared in SARS-CoV-2 infected but not H1N1 influenza infected lung cells. The lung cells-characteristic DANCR and NEAT1 association with inflammation-controlling transcripts could not be observed in blood cells, weakened with age and presented sex-dependent links in GTEx lung RNA-seq dataset. Supporting active involvement in the inflammatory risks accompanying COVID-19, DANCR's decline associated with decrease of the COVID-19-related cellular transcript ACE2 and with sex-related increases in coding transcripts potentiating acetylcholine signaling. Furthermore, transcription factors (TFs) in lung, brain and cultured infected cells created networks with the candidate transcripts, indicating tissue-specific expression patterns. Supporting links of post-infection inflammatory and cognitive damages with cholinergic mal-functioning, man and woman-originated cultured cholinergic neurons presented differentiation-related increases of DANCR and NEAT1 targeting microRNAs. Briefly, changes in ncRNAs and TFs from inflammation-prone human lung tissues, SARS-CoV-2-infected lung cells and man and woman-derived differentiated cholinergic neurons reflected the inflammatory pathobiology related to COVID-19. By shifting ncRNA differences into comparative diagnostic and therapeutic profiles, our RNA-sequencing based Resource can identify ncRNA regulating candidates for COVID-19 and its associated immediate and predicted long-term inflammation and neurological complications, and sex-related therapeutics thereof. Our findings encourage diagnostics of involved tissue, and further investigation of NEAT1-inducing statins and anti-cholinergic medications in the COVID-19 context.

Risk of subsequent ischemic stroke in patients with nontyphoidal salmonellosis: A nationwide population-based cohort study

OBJECTIVES

To explore the association between nontyphoidal salmonellosis (NTS) and the risk of acute ischemic stroke (IS) by using a nationwide, population-based study.

METHODS

A retrospective cohort study using claim data from Taiwan's National Health Insurance Research Database (NHIRD), patients aged 18 years and older with histories of NTS (N = 1618) were included from January 1, 2000-December 31, 2012, and the non-NTS group (N = 6472) without NTS were matched by propensity score. The follow-up period was defined as the time from the initial diagnosis of NTS to the date of development of IS, death or 31 December, 2013. Patients previously diagnosed with stroke were excluded. The Cox proportional hazard model with robust sandwich estimator was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) of IS after adjusting for demographic and clinical covariates.

RESULTS

The adjusted hazard ratio (aHR) for the NTS group compared with the non-NTS group was 1.34 (95% confidence interval [CI], 1.10-1.65) for overall stroke. Furthermore, the NTS cohort had an increased risk of IS compared to the non-NTS groups (aHR, 1.42; 95% CI, 1.14-1.78). Stratified analysis showed that compared with propensity score matched non-NTS group, subjects aged ≥65 years, female, those with hypertension, hyperlipidemia, COPD, cancer and heart failure had higher risk of developing stroke. A 1.93-fold significant increase risk for stroke was observed during the first 3-12 months of follow-up (95% CI, 1.07-3.48).

CONCLUSIONS

Patients with NTS is associated with increased risk of developing ischemic stroke compared with non-NTS patients. Timely and mindful treatment plan about NTS may be a milestone to stroke prevention especially in some subpopulation.

Vascular injury biomarkers and stroke risk

Objective

Because little is known about associations between biomarkers of vascular injury and stroke risk, we evaluated associations between plasma concentrations of 6 novel biomarkers of vascular injury and stroke risk in a population-based study.

Methods

A case–cohort subset of EPIC-Heidelberg (European Prospective Investigation for Cancer and Nutrition–Heidelberg) including incident stroke cases (n = 335) and a random subcohort (n = 2,418) was selected. Concentrations of intercellular adhesion molecule 3 (ICAM3), soluble E-selectin and P-selectin, soluble thrombomodulin (sTM), thrombopoietin, and glycoprotein IIb/IIIa were measured in baseline plasma samples. Weighted Cox regression analyses were used to assess associations between biomarker levels and stroke risk.

Results

Median follow-up in the subcohort and among cases was 9.8 (range, 0.1–12.5) years and 6.2 (range, 0.01–12.1) years, respectively. ICAM3 levels were associated with increased risk of incident stroke after multivariable adjustment (hazard ratio, highest vs lowest quartile: 1.64 [95% confidence interval, 1.15–2.32]; plinear trend < 0.001). This association was more apparent for ischemic (1.65 [1.12–2.45]; plinear trend < 0.01) than for hemorrhagic stroke (1.29 [0.60–2.78]; plinear trend = 0.3). We further observed a borderline significant trend for a positive association between sTM and overall stroke risk (1.47 [0.99–2.19]; plinear trend = 0.05).

Conclusions

In this population-based study, circulating levels of ICAM3, an adhesion molecule shed by leukocytes, were associated with increased risk of incident stroke. Further mechanistic studies are needed to elucidate the pathophysiology underlying this association.

Classification of evidence

This study provides Class II evidence that plasma levels of ICAM3 are associated with increased stroke risk.

Leukocyte Counts and Ratios Are Predictive of Stroke Outcome and Hemorrhagic Complications Independently of Infections

Background: Ischemic stroke patients show alterations in peripheral leukocyte counts that may result from the sterile inflammation response as well as the occurrence of early infections. We here aimed to determine whether alterations of circulating leukocytes in acute ischemic stroke are associated with long-term functional outcome and hemorrhagic complications, independently of the occurrence of infections. Methods: Blood laboratory values of patients with acute ischemic stroke, presenting within 4.5 h from symptom onset, were collected. Leukocyte subsets were analyzed in relation to 3-month functional outcome, mortality, and parenchymal hemorrhagic transformation (PH). A multivariable logistic regression analysis, considering the occurrence of early post-stroke infections, was performed for each outcome measure. Results: Five-hundred-ten patients were included in the study. Independently of infections, good functional outcome was associated with a lower neutrophil to lymphocyte ratio (NL-R, OR 0.906 [95% CI 0.822-0.998]), a higher lymphocyte count (OR 1.547 [95% CI 1.051-2.277]), a higher eosinophil count (OR 1.027 [95% CI 1.007-1.048]), and a higher eosinophil to leukocyte ratio (EoLeu-R, OR 1.240 [95% CI 1.071-1.436]) at admission. Death within 3 months was associated with higher NL-R (OR 1.103 [95% CI 1.032-1.179]) as well as with lower eosinophil counts (OR 0.909 [95% CI 0.827-0.999]). Patients developing parenchymal hemorrhagic transformation had higher neutrophil counts (OR 1.420 [95% CI 1.197-1.684]) as well as a higher NL-R (OR 1.192 [95% IC 1.088-1.305]). Conclusion: Leukocyte subtype profiles in the acute phase of ischemic stroke represent a predictor of outcome independently of infections. Stroke-evoked sterile inflammation is a pathophysiological relevant mechanism that deserves further investigation.

Utility of procalcitonin for diagnosis of bacterial infection-related systemic inflammatory response in the acute neurologic injury population

OBJECTIVE

Inflammation and bacterial infection are common complicating factors in the treatment of patients with stroke. Inflammatory responses can manifest as systemic inflammatory response syndrome (SIRS), a condition with both infectious and non-infectious etiologies. Accurately identifying patients with infection-related SIRS is important for determining the correct treatment plan. Here, we investigated the use of the glycopeptide procalcitonin (PCT) as a potential biomarker for identifying patients with bacterial infections in the setting of SIRS.

PATIENTS AND METHODS

A retrospective chart review was performed for adult patients admitted to United Hospital with an admission or discharge diagnosis of stroke for whom PCT testing was ordered between January 2011 and December 2014. Medical records were searched for the timing of PCT tests, and the previous 24 h was assessed for markers of SIRS, inflammation, and disease severity.

RESULTS

PCT levels were negatively correlated with Glasgow Coma Scale scores (ρ=-0.27, p < 0.0001) and glomerular filtration rates (ρ=-0.22, p < 0.001), but demonstrated a positive correlation with white blood cell (WBC) count (ρ = 0.13, p = 0.031) and creatinine levels (ρ = 0.33, p < 0.0001). PCT levels were significantly higher in samples that corresponded to the presence of at least one infection (p < 0.0001) and in SIRS + samples (p < 0.001). However, even with the addition of a SIRS + diagnosis, the predictive value of PCT did not reach levels that would indicate clinical utility for the identification of patients with bacterial infections.

CONCLUSIONS

PCT was not a viable biomarker for distinguishing between infectious and non-infections etiologies of SIRS in acute brain injury in this population. However, our results do indicate potential utility for PCT as an indicator for the cessation of antibiotic use in acute brain injury patients with bacterial infections.

Risk of ischemic stroke after discharge from inpatient surgery: Does the type of surgery matter?

OBJECTIVE

Stroke is a well-known and devastating complication during the perioperative period. However, detailed stroke risk profiles within 90 days in patients discharged without stroke after inpatient surgery are not fully understood. Using the case-crossover design, we aimed to evaluate the risk of ischemic stroke in these patients.

METHODS

We included adult patients with the first hospitalization for ischemic stroke between 2011 and 2012 from 23 million enrollees in the National Health Insurance Research Database. Admission date of the hospitalization was defined as the case day and exactly 365 days before the admission date as the control day. The exposure was the last hospitalization for surgery within 1-30, 31-60, or 61-90 days (case period) before the case day or similar time intervals (control period) before the control day. Surgical types were grouped based on the International Classification of Diseases procedure codes. We performed conditional logistic regression adjusting for time-varying variables to determine the relationship between surgery and subsequent stroke, and case-time-control analyses to examine whether the results were confounded by the time-trend in surgery.

RESULTS

A total of 56596 adult patients (41% female, mean age 69 years) comprised the study population. After adjustment was made for confounding variables, an association between stroke and prior inpatient surgery within 30 days was observed (adjusted odds ratio 1.44; 95% confidence interval 1.29-1.61). Cardiothoracic, vascular, digestive surgery, and musculoskeletal surgery within 30 days independently predicted ischemic stroke in the case-crossover analysis. In the case-time-control analysis, inpatient surgery remained an independent risk factor for ischemic stroke, whereas only cardiothoracic, vascular, and digestive surgery independently predicted ischemic stroke.

CONCLUSIONS

Surgery as a whole independently increased the risk of ischemic stroke within 30 days. Among various types of surgery, cardiothoracic, vascular, and digestive surgery significantly increased the risk of ischemic stroke.

Two-way Interaction Effects of Perioperative Complications on 30-Day Mortality in General Surgery

BACKGROUND

Multiple perioperative complications increase mortality risk, and certain complications synergistically increase this risk to a greater degree than might be expected if the complications were independent, but these effects are not well established.

METHODS

This is a retrospective cohort study of 422,827 intraabdominal general surgery patients (American College of Surgeons National Surgical Quality Improvement Program 2005-2011). Eight complications were evaluated: acute respiratory failure (ARF), acute kidney injury (AKI), sepsis/septic shock, stroke, cardiac arrest (CA), myocardial infarction (MI), deep vein thrombosis/pulmonary embolus, and transfusion. Each combination of two complications (28 total) was modeled using a Cox model for 30-day mortality, with adjustment for preoperative comorbidities and risk factors. Additive interaction was determined with the relative excess risk due to interaction (RERI). A positive RERI indicates that the mortality risk with both complications is greater than the sum of the individual mortality risks. Bonferroni correction was applied (α = 0.05/28 = 0.0018).

RESULTS

Seven combinations demonstrated positive interaction: sepsis-CA (RERI 88.1; p < 0.0001), ARF-AKI (RERI 50.5; p < 0.0001), AKI-sepsis (RERI 33.9; p < 0.0001), sepsis-stroke (RERI 33.9; p < 0.0001), ARF-stroke (RERI 32.3; p < 0.0001), AKI-MI (RERI 24.5; p = 0.0013), and ARF-sepsis (RERI 19.2; p < 0.0001). Two combinations demonstrated negative interaction: ARF-CA (RERI -65.1; p = 0.0017) and CA-transfusion (RERI -52.0, p < 0.0001).

CONCLUSIONS

Interaction effects exist between certain complications to increase the risk of short-term mortality. ARF, AKI, sepsis, and stroke were most likely to be involved in positive interactions. Further research into the mechanisms for these effects will be necessary to develop strategies to minimize the compounding effects of multiple complications in the perioperative period.

Practice Patterns of Venous Thromboembolism Prophylaxis in Underweight, Critically Ill Patients with Neurologic Injury

PURPOSE

Venous thromboembolism (VTE) prophylaxis in underweight patients with neurologic injury remains unaddressed by guidelines and primary literature. This study aimed to describe VTE prophylaxis strategies employed in this population and compare the impact of underweight and non-obese patients on thrombotic and bleeding events.

METHODS

A retrospective review of adults admitted with a diagnosis of neurologic injury to a neurology/neurosurgery intensive care unit (ICU) over 6 years. Patients admitted ≥72 h with an order for VTE prophylaxis during admission, and a body mass index (BMI) <30 kg/m² were included. Patients were stratified to underweight (BMI ≤18.5 kg/m² or weight ≤50.0 kg) or non-obese (BMI 18.6-29.9 kg/m²) groups and matched, 2:1, on age, diagnosis, and disease severity.

RESULTS

The most common regimen in the underweight (n = 107) and non-obese (n = 214) group was unfractionated heparin (UFH) 5000 units subcutaneously Q12 h (69.1 vs. 83.6%; p = 0.003). Only underweight patients received UFH 2500 units subcutaneously Q12 h (17.8 vs. 0.0%; p < 0.0001). The proportion of overall bleeding and thrombotic events while receiving VTE prophylaxis was not significantly different. The proportion of underweight patients developing intracranial hematoma expansion while receiving prophylaxis versus non-obese patients (45.5 vs. 8.3%; p = 0.017) was significant. Patients receiving >150 units/kg/day of UFH displayed a trend toward increased risk of bleeding (9.7 vs. 4.2%; p = 0.064).

CONCLUSIONS

Current practice does not reflect dose reductions for neurologically injured, underweight patients. Caution should be considered when using increased doses of UFH in neurologically injured patients that are underweight and/or may be exposed to >150 units/kg/day of UFH. Continued assessment of VTE prophylaxis is needed to confirm these findings.

Placental Pathology in Neonatal Stroke: A Retrospective Case-Control Study

OBJECTIVE

To assess the association of placental abnormalities with neonatal stroke.

STUDY DESIGN

This retrospective case-control study at 3 academic medical centers examined placental specimens for 46 children with neonatal arterial or venous ischemic stroke and 99 control children without stroke, using a standard protocol. Between-group comparisons used χ² and Fisher exact t test. Correlations used Spearman correlation coefficient.

RESULTS

Case placentas were more likely than controls to meet criteria for ≥1 of 5 major categories of pathologic abnormality (89% vs 62%; OR, 5.1; 95% CI, 1.9-14.0; P = .0007) and for ≥2 categories (38% vs 8%; OR, 7.3; 95% CI, 2.9-19.0; P < .0001). Fetal vascular malperfusion occurred in 50% of cases and 17% of controls (OR, 4.8; 95% CI, 2.2-10.5; P = .0001). Amniotic fluid inflammation occurred in 46% of cases with arterial ischemic stroke vs 25% of controls (OR, 2.6; 95% CI, 1.1-6.1; P = .037). There was evidence of a "stress response" (meconium plus elevated nucleated red blood cells) in 24% of cases compared with 1% of controls (OR, 31; 95% CI, 3.8-247.0; P < .0001).

CONCLUSIONS

Placental abnormality was more common in children with neonatal stroke compared with controls. All placental findings represent subacute-to-chronic intrauterine stressors. Placental thrombotic processes were associated with both arterial and venous stroke. Our findings provide evidence for specific mechanisms that may predispose to acute perinatal stroke. Amniotic fluid inflammation associated with neonatal arterial ischemic stroke deserves further investigation.

Immunological, vascular, metabolic, and autonomic changes seen with aging possible implications for poor outcomes in the elderly following decompressive hemicraniectomy for malignant MCA stroke: a critical review

INTRODUCTION

Stroke is one of the leading causes of mortality and morbidity worldwide and requires rapid and intensive treatment to prevent adverse outcomes. Decompressive hemicraniectomy stands as the gold standard for surgical resolution of the intracranial swelling which accompanies cerebral infarction; however, the benefits of this procedure are not as well achieved in the elderly (age >65 years) compared to the younger population.

EVIDENCE ACQUISITION

This is a critical review performed on all available literature relating to middle cerebral artery (MCA) stroke in the elderly with emphasis on articles examining causality of adverse outcomes in this group over younger populations. Utilizing PRISMA guidelines, we initially identified 1462 articles.

EVIDENCE SYNTHESIS

After screening, four clear areas of physiological change associated with aging were identified and expounded upon as they relate to MCA stroke. These four areas include: immunological, autonomic, mitochondrial, and vascular changes. Elderly patients have a decreased and declining capacity to regulate the inflammation that develops postinfarction and this contributes to adverse outcomes from a neurological stand point. Additionally, aging decreases the ability of elderly patients to regulate their autonomic system resulting in aberrant blood pressures systemically post infarction. With age, the mitochondrial response to ischemia is exaggerated and causes greater local damage in elderly patients compared to younger populations. Finally, there are numerous vascular changes that occur with age including accumulation of homocysteine and atherosclerosis which together contributed to decreased structural integrity of the vasculature in the elderly and render decreased support to the recovery process post infarction.

CONCLUSIONS

We conclude that physiological changes inherent in the aging process serve to intensify adverse outcomes that are commonly associated with strokes in the elderly. Identification and subsequent minimization of these risk factors could allow for more effective management of elderly patients, post stroke, and promote better clinical outcomes.

Mass spectrometry for the evaluation of cardiovascular diseases based on proteomics and lipidomics

The identification and quantification of proteins and lipids is of major importance for the diagnosis, prognosis and understanding of the molecular mechanisms involved in disease development. Owing to its selectivity and sensitivity, mass spectrometry has become a key technique in analytical platforms for proteomic and lipidomic investigations. Using this technique, many strategies have been developed based on unbiased or targeted approaches to highlight or monitor molecules of interest from biomatrices. Although these approaches have largely been employed in cancer research, this type of investigation has been met by a growing interest in the field of cardiovascular disorders, potentially leading to the discovery of novel biomarkers and the development of new therapies. In this paper, we will review the different mass spectrometry- based proteomic and lipidomic strategies applied in cardiovascular diseases, especially atherosclerosis. Particular attention will be given to recent developments and the role of bioinformatics in data treatment. This review will be of broad interest to the medical community by providing a tutorial of how mass spectrometric strategies can support clinical trials.

Association of SAA gene polymorphism with ischemic stroke in northern Chinese Han population

BACKGROUND

Serum amyloid A protein (SAA) is known as an inflammatory factor and an apolipoprotein that can replace apolipoprotein A-I/II components as the major apolipoprotein of high-density lipoprotein (HDL), which is related to atherosclerosis. The present study is aimed to evaluate whether the SAA gene polymorphism is involved in ischemic stroke in northern Chinese Han population.

METHODS

In a case-control study, the participants included 396 patients (239 males, 157 females) with ischemic stroke and 360 healthy subjects (211 males, 149 females). The rs12218 polymorphism of the SAA gene was analyzed by polymerase chain reaction and restriction fragment length polymorphism, while the rs2468844 polymorphism of the SAA gene was analyzed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

RESULTS

The frequencies of the CC genotype and the C allele of rs12218 were higher in participants with ischemic stroke than in the control group (P=0.020 in males, P=0.001 in large-artery atherosclerosis group, LAA). The frequencies of the AG genotype and the G allele of rs2468844 were higher in participants with ischemic stroke than in the control group (P=0.040 in males, P=0.011 in large-artery atherosclerosis group). Multiple logistic regression analysis revealed the significance of the rs12218 in males and in large-artery atherosclerosis group after adjustment for confounding factors.

CONCLUSION

The rs12218 polymorphism of the SAA gene was associated with ischemic stroke in males and in patients with large-artery atherosclerosis group in northern Chinese Han population.

Predictive value of serum transthyretin for outcome in acute ischemic stroke

Introduction

The impact of choroid plexus with its blood–cerebrospinal fluid barrier in the ischemic stroke pathology is poorly explored. Transthyretin (TTR) is a protein synthesized in liver and just in choroid plexus.

Objectives

The current study was designed to assess the prognostic value of serum TTR for functional outcome (at the time of hospital discharge) and long-term (one-year) overall mortality in ischemic stroke patients.

Patients and methods

We conducted a prospective observational study. Patients (n = 81) with acute (< 24 hours of symptoms onset) ischemic stroke consecutively admitted to Stroke Unit were included. An unfavorable outcome was defined as a modified Rankin Scale (mRS) score ≥ 3. The relationships between serum TTR levels and clinical outcome were analyzed using multivariate analysis. One-year mortality was analyzed by Kaplan–Meier survival curves stratified by mean value of TTR.

Results

Compared with patients with mRS <3, patients with an unfavorable outcome at hospital discharge had significantly lower TTR levels on admission (P < 0.0001). In non-survivals serum TTR levels were significantly lower compared with patients who survive one year of observation (P = 0.009). Using multivariate analysis, transthyretin emerged as an independent predictor for unfavorable outcome at the day of hospital discharge (adjusted odds ratio = 0.96; 95% CI: 0.9–0.99, P <0.05). A one-year mortality of patients with the lower TTR levels was significantly higher than in patients with TTR levels above mean value (P = 0.02).

Conclusions

Serum level of TTR at admission was a predictor of functional outcome after ischemic stroke and was also associated with one-year mortality in stroke survivals.

Cardioembolic Stroke

Cardiac embolism accounts for an increasing proportion of ischemic strokes and might multiply several-fold during the next decades. However, research points to several potential strategies to stem this expected rise in cardioembolic stroke. First, although one-third of strokes are of unclear cause, it is increasingly accepted that many of these cryptogenic strokes arise from a distant embolism rather than in situ cerebrovascular disease, leading to the recent formulation of embolic stroke of undetermined source as a distinct target for investigation. Second, recent clinical trials have indicated that embolic stroke of undetermined source may often stem from subclinical atrial fibrillation, which can be diagnosed with prolonged heart rhythm monitoring. Third, emerging evidence indicates that a thrombogenic atrial substrate can lead to atrial thromboembolism even in the absence of atrial fibrillation. Such an atrial cardiomyopathy may explain many cases of embolic stroke of undetermined source, and oral anticoagulant drugs may prove to reduce stroke risk from atrial cardiomyopathy given its parallels to atrial fibrillation. Non-vitamin K antagonist oral anticoagulant drugs have recently expanded therapeutic options for preventing cardioembolic stroke and are currently being tested for stroke prevention in patients with embolic stroke of undetermined source, including specifically those with atrial cardiomyopathy. Fourth, increasing appreciation of thrombogenic atrial substrate and the common coexistence of cardiac and extracardiac stroke risk factors suggest benefits from global vascular risk factor management in addition to anticoagulation. Finally, improved imaging of ventricular thrombus plus the availability of non-vitamin K antagonist oral anticoagulant drugs may lead to better prevention of stroke from acute myocardial infarction and heart failure.

Distinct Roles of Endothelial Dysfunction and Inflammation in Intracranial Atherosclerotic Stroke

BACKGROUND/AIMS

The aim of the study was to evaluate the differential roles of endothelial dysfunction and inflammation in intracranial atherosclerotic stroke (ICAS).

METHODS

We prospectively recruited 262 patients with acute cerebral infarcts caused by ICAS and 75 individuals with no history of stroke as controls. Markers of endothelial dysfunction (asymmetric dimethylarginine, ADMA) and inflammation (lipoprotein-associated phospholipase A2, Lp-PLA2) were measured. Acute ischemic lesions were measured in terms of their size, composition, and patterns. Subclinical microangiopathy (degree of leukoaraiosis) and macroangiopathy (presence/number of asymptomatic stenoses) were graded in each patient.

RESULTS

Compared to normal controls, serum levels of ADMA (0.69 ± 0.14 vs. 0.47 ± 0.10, p < 0.001) and Lp-PLA2 (138.1 ± 116.8 vs. 19.0 ± 58.0, p < 0.001) were elevated in patients with ICAS. A high ADMA serum level was associated with greater prevalence of preclinical microangiopathy and macroangiopathy. Contrastingly, an elevated serum Lp-PLA2 level was associated with larger ischemic lesions, a greater number of lesions, and a larger cortical pattern.

CONCLUSIONS

Endothelial dysfunction and inflammation have distinct effects in ICAS patents; endothelial dysfunction is associated with the underlying micro- and macro-atherosclerotic burden, whereas inflammation is associated with acute infarct volume and pattern.

Carotid intima media thickness and blood biomarkers of atherosclerosis in patients after stroke or myocardial infarction

AIM

To test if circulating levels of markers of inflammation, endothelial function, and chronic infections, as well as association between these markers and carotid intima media thickness (CIMT), depend on the stage of atherosclerosis expressed as a history of a major vascular event.

METHODS

The associations were analyzed separately in 75 healthy controls, 79 patients 3-6 months after the first-ever non-cardioembolic ischemic stroke (IS), and 37 patients 3-6 months after the first-ever myocardial infarction (MI). Data were collected prospectively in 2005. We measured high sensitivity C-reactive protein (hs-CRP), procalcitonin, E-selectin, intercellular adhesion molecule-1 (ICAM-1), serum level of immune complexes (IC), and identified antibodies against Herpes simplex virus type 1 (HSV), Cytomegalovirus, Chlamydia pneumonia, and Helicobacter pylori. Correlations with CIMT were determined using Pearson R and verified after adjustment for age, sex, hypertension, diabetes, and statin therapy.

RESULTS

Median ICAM-1 concentration was significantly lower in controls than in post-IS patients (188 μg/L vs 215 μg/L), and significantly lower in post-IS patients than in post-MI patients (215 μg/L vs 260 μg/L). Control patients also had significantly lower IC level (0.03 U/L) and HSV antibody index (6.0) compared to both post-IS (0.6 U/L, 9.6) and post-MI (0.4 U/L, 9.2) patients. CIMT was correlated with age (Pearson R=0.38, P=0.001) in the control group, immune complexes (R=0.26, P=0.023) in the post-IS group, and with hs-CRP (R=0.40, P=0.017) in the post-MI group. These correlations were confirmed using multiple regression analysis.

CONCLUSIONS

Our study supports linear correlations between CIMT and IC and hs-CRP levels. However, these associations seem to depend on the type of vascular burden.

Stroke caused by an inflammatory thrombus: a case report

Background

Stroke is the leading cause of mortality and disability worldwide. Several definite risk factors have been identified for stroke, although infectious factors might also contribute to stroke episodes through increased susceptibility or direct induction.

Case presentation

A 46-year-old Chinese male initially presented with fever, headache, and impaired memory and developed disturbance of consciousness after admission. A clinical diagnosis of Staphylococcus aureus sepsis, massive cerebral infarction and haemorrhagic transformation (left internal carotid arterial system, inflammatory thrombus) were made based on brain radiography, blood culture and postoperative pathological examinations. These symptoms improved following antibiotic therapy with vancomycin and conventional treatments for stroke.

Conclusion

For stroke patients without traditional cerebrovascular risk factors but with signs of infection, infectious causes should be considered.

Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study

OBJECTIVE

 To evaluate whether patients with migraine are at increased risk of perioperative ischemic stroke and whether this may lead to an increased hospital readmission rate.

DESIGN

 Prospective hospital registry study.

SETTING

 Massachusetts General Hospital and two satellite campuses between January 2007 and August 2014.

PARTICIPANTS

 124 558 surgical patients (mean age 52.6 years; 54.5% women).

MAIN OUTCOME MEASURES

 The primary outcome was perioperative ischemic stroke occurring within 30 days after surgery in patients with and without migraine and migraine aura. The secondary outcome was hospital readmission within 30 days of surgery. Exploratory outcomes included post-discharge stroke and strata of neuroanatomical stroke location.

RESULTS

 10 179 (8.2%) patients had any migraine diagnosis, of whom 1278 (12.6%) had migraine with aura and 8901 (87.4%) had migraine without aura. 771 (0.6%) perioperative ischemic strokes occurred within 30 days of surgery. Patients with migraine were at increased risk of perioperative ischemic stroke (adjusted odds ratio 1.75, 95% confidence interval 1.39 to 2.21) compared with patients without migraine. The risk was higher in patients with migraine with aura (adjusted odds ratio 2.61, 1.59 to 4.29) than in those with migraine without aura (1.62, 1.26 to 2.09). The predicted absolute risk is 2.4 (2.1 to 2.8) perioperative ischemic strokes for every 1000 surgical patients. This increases to 4.3 (3.2 to 5.3) for every 1000 patients with any migraine diagnosis, 3.9 (2.9 to 5.0) for migraine without aura, and 6.3 (3.2 to 9.5) for migraine with aura. : Patients with migraine had a higher rate of readmission to hospital within 30 days of discharge (adjusted odds ratio 1.31, 1.22 to 1.41).

CONCLUSIONS

 Surgical patients with a history of migraine are at increased risk of perioperative ischemic stroke and have an increased 30 day hospital readmission rate. Migraine should be considered in the risk assessment for perioperative ischemic stroke.

Risk of coronary artery disease in celiac disease population

BACKGROUND/AIMS

Celiac disease (CD), a chronic autoimmune condition, is associated with systemic inflammation capable of causing extra intestinal manifestations. Chronic inflammatory process has been implicated in the pathogenesis of accelerated atherosclerosis. Studies examining the burden of coronary artery disease (CAD) in patients with CD are lacking. We evaluated the prevalence of CAD in patients with CD.

PATIENTS AND METHODS

Electronic health records from different health care systems were obtained utilizing a Health Insurance Portability and Accountability Act-compliant, patient de-identified web application. Among the 48,642,290 patients, 59,010 were diagnosed with CD. The remaining 48,583,280 patients without CD served as comparison controls.

RESULTS

The prevalence of CAD was significantly higher in patients with CD than in the controls [5140 (8.7%) vs. 2119060 (4.4%), P < 0.001], with the odds ratio (OR) being 2.09 (95% confidence interval [CI]: 2.03-2.15, P < 0.0001). There was a similarly higher prevalence among younger patients (age, <65 years) with CD compared with those without CD (3.72% vs 1.98% [OR: 1.85, 95% CI: 1.7488-1.9417, P < 0.0001).

CONCLUSIONS

The prevalence of CAD increased nearly two-fold in patients with CD.

Risk of stroke among patients with cerebral palsy: a population-based cohort study

AIM

The aim of the study was to investigate the risk of stroke in patients with cerebral palsy (CP), based on nationwide data in Taiwan.

METHOD

This prospective cohort study was comprised of patients recorded on the Taiwan Longitudinal Health Insurance Database 2005 (LHID2005) who had a diagnosis of CP (n=1975) in records between 1 January 2004 and 31 December 2007. A comparison group (1:5) drawn from the same database was matched for age and sex (n=9875). Each patient was tracked by data until the development of stroke or the end of 2008. Cox proportional-hazards regression analysis was used to evaluate the hazard ratios after adjusting for potential confounding factors.

RESULTS

Patients with CP were more likely to suffer stroke than the comparison population, after adjusting for potential confounding factors (adjusted hazard ratio: 2.17; 95% confidence interval [CI]: 1.74-2.69). The hazard ratio of stroke was 4.78 (95% CI: 3.18-7.17) and 1.57 (95% CI: 1.20-2.05) for patients with CP aged 50 years and under, and over 50 years respectively.

INTERPRETATION

Cerebral palsy is a risk factor or marker for stroke that is independent of traditional stroke risk factors. Further research in this area is warranted.

Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society

The risk of death from venous thromboembolism (VTE) is high in intensive care unit patients with neurological diagnoses. This is due to an increased risk of venous stasis secondary to paralysis as well as an increased prevalence of underlying pathologies that cause endothelial activation and create an increased risk of embolus formation. In many of these diseases, there is an associated risk from bleeding because of standard VTE prophylaxis. There is a paucity of prospective studies examining different VTE prophylaxis strategies in the neurologically ill. The lack of a solid evidentiary base has posed challenges for the establishment of consistent and evidence-based clinical practice standards. In response to this need for guidance, the Neurocritical Care Society set out to develop and evidence-based guideline using GRADE to safely reduce VTE and its associated complications.

Perioperative stroke after carotid endarterectomy: etiology and implications

BACKGROUND

Carotid endarterectomy (CEA) is the procedure of choice for reducing the risk of stroke in both symptomatic and asymptomatic carotid artery stenoses. Stroke is associated with significant morbidity and mortality peri-operatively (2-3 %). Our primary aim is to evaluate the etiology of these strokes after CEA and their impact on morbidity by comparing the length of stay in the hospital.

METHODS

A total of 584 patients with documented neurological status evaluations who underwent CEAs were included in the study. Neurophysiological monitoring data was obtained during CEA for carotid stenosis included eight-channel electroencephalography (EEG) and upper extremity somatosensory evoked potentials (SSEPs).

RESULTS

Twenty-one (3.595 %) patients had strokes in the perioperative period and they were more likely to have left-sided surgery (p = 0.008), intraoperative monitoring (IOM) changes (p < 0.001), an intraoperative shunt placed (p = 0.0002) or a hospital stay longer than 5 days (p = 0.0042). Unilateral anterior circulation ischemic stroke were the most common in our series. In a logistic regression model, left-sided surgery was shown to be 4.78 times more likely to be associated with perioperative stroke (1.50-15.27; p = 0.008) while intraoperative shunts were 11.85 times more likely to have strokes (3.97-35.34; p < 0.0001). Patients with stenosis greater than 70 % were 6.67 times less likely to have a stroke (0.04-0.59; p = 0.007).

CONCLUSIONS

Ischemic anterior circulation strokes are the most common type of post-operative neurological changes in patients undergoing CEA. Intraoperative shunt placement was a strong predictor of perioperative strokes. Since shunts are only placed following intraoperative monitoring changes, SSEPs and EEG can therefore function as a biomarker of cerebral hypo-perfusion.

Chronic Rhinosinusitis Associated with Erectile Dysfunction: A Population-Based Study

Few studies have investigated the relationship between chronic rhinosinusitis (CRS) and erectile dysfunction (ED). This case-control study aimed to investigate the association between CRS and the risk of ED in a large national sample. Tapping Taiwan's National Health Insurance Research Database, we identified people 30 years or older with a new primary diagnosis of CRS between 1996 and 2007. The cases were compared with sex- and age-matched controls. We identified 14 039 cases and recruited 140 387 matched controls. Both groups were followed up in the same database until the end of 2007 for instances of ED. Of those with CRS, 294 (2.1%) developed ED during a mean (SD) follow-up of 3.20 (2.33) years, while 1 661 (1.2%) of the matched controls developed ED, mean follow up 2.97 (2.39) years. Cox regression analyses were performed adjusting for sex, age, insurance premium, residence, hypertension, hyperlipidemia, diabetes, obesity, coronary heart disease, chronic kidney disease, chronic obstructive pulmonary disease, asthma, allergic rhinitis, arrhythmia, ischemic stroke, intracerebral hemorrhage, and medications. CRS was revealed to be an independent predictor of ED in the fully adjusted model (HR = 1.51; 95% CI = 1.33-1.73; P < 0.0001).

Hydrogen-rich water attenuates brain damage and inflammation after traumatic brain injury in rats

Inflammation and oxidative stress are the two major causes of apoptosis after traumatic brain injury (TBI). Most previous studies of the neuroprotective effects of hydrogen-rich water on TBI primarily focused on antioxidant effects. The present study investigated whether hydrogen-rich water (HRW) could attenuate brain damage and inflammation after traumatic brain injury in rats. A TBI model was induced using a controlled cortical impact injury. HRW or distilled water was injected intraperitoneally daily following surgery. We measured survival rate, brain edema, blood-brain barrier (BBB) breakdown and neurological dysfunction in all animals. Changes in inflammatory cytokines, inflammatory cells and Cho/Cr metabolites in brain tissues were also detected. Our results demonstrated that TBI-challenged rats exhibited significant brain injuries that were characterized by decreased survival rate and increased BBB permeability, brain edema, and neurological dysfunction, while HRW treatment ameliorated the consequences of TBI. HRW treatment also decreased the levels of pro-inflammatory cytokines (TNF-α, IL-1β and HMGB1), inflammatory cell number (Iba1) and inflammatory metabolites (Cho) and increased the levels of an anti-inflammatory cytokine (IL-10) in the brain tissues of TBI-challenged rats. In conclusion, HRW could exert a neuroprotective effect against TBI and attenuate inflammation, which suggests HRW as an effective therapeutic strategy for TBI patients.

Safety and Therapeutic Potential of M2 Macrophages in Stroke Treatment

Our objective was to evaluate the safety and clinical efficacy of autologous M2 macrophage transplantation in nonacute stroke patients. We also evaluated whether the intrathecal administration of macrophages influences the production of cytokines by peripheral blood cells and whether the levels of cytokines correlate with stroke severity and responsiveness to cell therapy. In this study, 13 patients (12 males and 1 female with a median age of 63 years) diagnosed with ischemic (n = 10) or hemorrhagic (n = 3) stroke were subjected to cell transplantation therapy (study group). On average, 21.9 × 10(6) autologous M2 macrophages were injected intrathecally. Thirteen matched case-control stroke patients who did not receive cell therapy comprised the control group. We did not observe any serious adverse events (i.e., intrahospital mortality, neurological worsening, and seizures) related to the cell injection. One patient in the study group and two patients in the control group died during the 6-month follow-up period due to recurrent stroke. In the study group, the NIHSS score decreased from 11 to 6 (p = 0.007) in 6 months after the therapy, whereas the patients in the control group showed a less pronounced neurological improvement (the NIHSS score decreased from 11 to 8, p = 0.07). The obvious positive response (the improvement of the NIHSS score ≥3) in the study group was observed in 75% versus 18% in the control group (pFET = 0.03). M2 cell introduction did not significantly affect the production of various cytokines. Nevertheless, pretreated levels of IL-8, IL-10, and IL-4 correlated with stroke severity. Moreover, responder patients had lower spontaneous production of IL-10, FGF-β, PDGF, VEGF, and higher stimulation indexes of IL-1β, TNF-α, IFN-γ, and IL-6 than nonresponders. These findings suggest that the intrathecal administration of autologous M2 cells in stroke patients is safe and leads to a better neurological recovery, which could be mediated through the immunomodulatory activity of M2 macrophages.