The prognostic value of biomarkers in stroke

A novel biomarker panel index improves risk stratification after ischemic stroke

Background:

We investigated 92 blood biomarkers implicated in the pathophysiological pathways of ischemic injury, inflammation, hemostasis, and regulation of vascular resistance to predict post-stroke mortality.

Aim:

Based on the most promising markers, we aimed to create a novel Biomarker Panel Index (BPI) for risk stratification.

Methods:

In this prospective study, we measured 92 biomarkers in 320 stroke patients. The primary outcome measure was mortality within 90 days. We estimated the association of each biomarker using logistic regression adjusting for multiple testing. The most significant 16 biomarkers were used to create the BPI. We fitted regression models to estimate the association and the discriminatory accuracy of the BPI with mortality and stroke etiology.

Results:

Adjusted for demographic and vascular covariates, the BPI remained independently associated with mortality (odds ratio (OR) 1.68, 95% confidence interval (CI): 1.29–2.18) and cardioembolic stroke etiology (OR 1.38, 95% CI: 1.10–1.74), and improved the discriminatory accuracy to predict mortality (area under the receiver operating characteristic curve (AUC) 0.93, 95% CI: 0.89–0.96) and cardioembolic stroke etiology (AUC 0.70, 95% CI: 0.64–0.77) as compared to the best clinical prediction models alone (AUC 0.89, 95% CI: 0.84–0.94 and AUC 0.66, 95% CI: 0.60-0.73, respectively).

Conclusions:

We identified a novel BPI improving risk stratification for mortality after ischemic stroke beyond established demographic and vascular risk factors. Furthermore, the BPI is associated with underlying cardioembolic stroke etiology. These results need external validation.

Association of Natriuretic Peptide With Adverse Outcomes and Disease Severity After Intracerebral Hemorrhage: A Systematic Review

Background: Over the past decade, many studies have reported the association of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) with clinical outcome of intracerebral hemorrhage (ICH). However, a broad consensus has not been reached. Objective: To evaluate the role of BNP/NT-proBNP levels in prognosis and disease severity assessment in patients with ICH. Methods: A systematic literature search was conducted utilizing PubMed, Embase, Web of Science and the Cochrane Library databases up to July 23, 2021. Studies that explored the association between BNP/NT-proBNP level and clinical outcome or disease severity in ICH patients were eligible. Outcome measures were all-cause mortality, poor functional outcome, adverse cardiac events and markers of disease severity. Results: Ten studies, involving 1,373 patients with ICH, met the inclusion criteria. Nine studies focused on clinical outcomes (five all-cause mortality, five functional outcomes, and one adverse cardiac event) and seven on disease severity. In terms of prognosis, all five studies showed an association between elevated BNP/NT-proBNP level and increased risk of all-cause mortality in ICH patients. Four of the five studies reported poor functional outcomes in patients with higher BNP/NT-proBNP levels and one study associated higher BNP/NT-proBNP levels with increased risk of adverse cardiac events. Moreover, two studies identified an additional predictive ability of BNP/NT-proBNP level beyond that of pre-existing prognostic variables. In terms of disease severity, five studies (71%) reported that BNP/NT-proBNP level correlated positively with hematoma volume in addition to ICH and GCS scores. Conclusion: Elevated BNP/NT-proBNP level is associated with increased risk of all-cause mortality, poor functional outcome, adverse cardiac events and disease severity in patients with ICH. Thus, BNP/NT-proBNP level is a promising prognostic indicator for ICH and also an effective marker of disease severity. Current evidence remains limited by the small number and high heterogeneity of included studies. Further appropriately designed, large-scale studies are required to confirm the current findings.

Analysis of Brain Natriuretic Peptide Levels after Traumatic Acute Subdural Hematoma and the Risk of Post-Operative Cerebral Infarction

Traumatic acute subdural hematoma (aSDH) is associated with a high mortality rate caused by post-operative cerebral infarction. Recently, brain natriuretic peptide (BNP) was considered a reliable biomarker in the acute phase of traumatic brain injuries. We therefore aimed in this study to analyze BNP levels on admission, identify the predictors of their elevation, and assess the relationship between BNP and the risk of post-operative cerebral infarction. Patients with isolated, unilateral, traumatic aSDH who were admitted to our department between July 2017 and May 2020 were enrolled in this study. On admission, cranial computer tomography (CCT) and BNP sampling were simultaneously performed. Additionally, the time between head trauma and BNP sampling (TTS) was assessed. Admission radiographic variables included hematoma volumes, midline shift, and degree of brain edema. Cerebral infarction was detected on postoperative CCT. In total, 130 patients were included in this study. Surgical treatment was performed in 82.3% (n = 107) of cases. The multiple regression analysis showed that larger hematoma volumes (p = 0.032) and advanced age (p = 0.005) were independent predictors of elevated BNP when TTS <24 h. The binomial logistical regression analysis identified BNP with a cutoff value of <29.4 pg/mL (TTS = 3-12 h, adjusted odds ratio [aOR] = 16.5, p = 0.023) as an independent predictor of post-operative cerebral infarction. Elevated BNP levels in the first 24 h post-trauma were related to larger hematoma volumes and advanced age. Further, an increased risk of post-operative cerebral infarction was identified in patients with lower BNP levels in the post-traumatic period 3-12 h.

Biomarkers Predictive of Long-Term Outcome After Ischemic Stroke: A Meta-Analysis

BACKGROUND AND PURPOSE

The goal of this study was to systematically review the utility of serum biomarkers in the setting of ischemic stroke (IS) to predict long-term outcome.

METHODS

A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986-2018. All studies assessing long-term functional outcome (defined as 30 days or greater) following IS with respect to serum biomarkers were included. Data were extracted and pooled using a meta-analysis of odds ratios.

RESULTS

Of the total 2928 articles in the original literature search, 183 studies were ultimately selected. A total of 127 serum biomarkers were included. Biomarkers were grouped into several categories: inflammatory (32), peptide/enzymatic (30), oxidative/metabolic (28), hormone/steroid based (23), and hematologic/vascular (14). The most commonly studied biomarkers in each category were found to be CRP, S100β, albumin, copeptin, and D-dimer. With the exception of S100β, all were found to be statistically associated with >30-day outcome after ischemic stroke.

CONCLUSIONS

Serum-based biomarkers have the potential to predict functional outcome in IS patients. This meta-analysis has identified CRP, albumin, copeptin, and D-dimer to be significantly associated with long-term outcome after IS. These biomarkers have the potential to serve as a platform for prognosticating stroke outcomes after 30 days. These serum biomarkers, some of which are routinely ordered, can be combined with imaging biomarkers and used in artificial intelligence algorithms to provide refined predictive outcomes after injury. Ultimately these tools will assist physicians in providing guidance to families with regards to long-term independence of patients.

Prognostic value of elevated high-sensitivity cardiac troponin T in acute ischemic stroke patients treated with endovascular thrombectomy in late time windows

OBJECTIVE

To evaluate the prognostic significance of high-sensitivity cardiac troponin T (hs-cTnT) elevation in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) in the anterior circulation treated with endovascular thrombectomy (ET) in late time windows and identify the factors associated with hs-cTnT elevation.

METHODS

A total of 152 AIS patients treated with ET in late time windows between January 2018 and August 2020 were included in this study. Patients were stratified into either normal or elevated hs-cTnT groups according to a cutoff value of 14 ng/L on admission. Baseline demographic features, comorbidities, and imaging data were compared between the elevated hs-cTnT group (＞14 ng/L) and the normal hs-cTnT group (≤14 ng/L). After accounting for these clinical characteristics, the association between hs-cTnT elevation and clinical outcomes was evaluated.

RESULTS

69(45.4%) patients had elevated hs-cTnT levels (>14 ng/L) on admission. The multivariable logistic regression analysis demonstrated that hs-cTnT elevation was independently associated with 3-month all-cause mortality (P = 0.014, OR 3.907, 95% CI 1.313-11.625) and 3-month composite unfavorable outcome (mRS 3-6) (P = 0.001, OR 5.099, 95% CI 1.873-13.888). Old age (P = 0.002, OR 1.053, 95% CI 1.020-1.088), admission NIHSS score (P = 0.015, OR 1.057, 95% CI 1.011-1.106), congestive heart failure (P = 0.016, OR 4.341, 95% CI 1.322-14.257) and coronary artery disease (P = 0.020, OR 2.914, 95% CI 1.183-7.180) were independently associated with hs-cTnT elevation.

CONCLUSION

In AIS patients treated with ET in late time windows, elevated hs-cTnT is independently associated with an increased risk of 3-month poor outcomes. Old age, high admission NIHSS score, coronary artery disease, and congestive heart failure are independent predictors of hs-cTnT elevation.

Association of Level and Increase in D-Dimer With All-Cause Death and Poor Functional Outcome After Ischemic Stroke or Transient Ischemic Attack

Background

D‐dimer is involved in poor outcomes of stroke as a coagulation biomarker. We aimed to investigate the associations of the level and increase in D‐dimer between baseline and 90 days with all‐cause death or poor functional outcome in patients after ischemic stroke or transient ischemic attack.

Methods and Results

We collected data from the CNSRIII (Third China National Stroke Registry) study. The present substudy included 10 518 patients within 7 days (baseline) of ischemic stroke or transient ischemic attack and 6268 patients at 90 days. Poor functional outcome at 1 year was assessed on the basis of the modified Rankin Scale (≥3). Multivariable Cox regression or logistic regression was used to assess the association of D‐dimer levels with all‐cause death or poor functional outcome. D‐dimer levels at 90 days were lower than those at baseline (1.4 µg/mL versus 1.7 µg/mL; P<0.001). Higher baseline D‐dimer level was associated with all‐cause death (adjusted hazard ratio [HR], 1.77; 95% CI, 1.25–2.52; P=0.001) and poor functional outcome (adjusted odds ratio [OR], 1.49; 95% CI, 1.23–1.80; P<0.001) during 1‐year follow‐up. Higher D‐dimer level at 90 days was also associated with poor outcomes independently. Furthermore, an increase in D‐dimer levels between baseline and 90 days was associated with all‐cause death (since 90 days to 1 year after index event) (adjusted HR, 1.99; 95% CI, 1.12–3.53; P=0.019) but not with poor functional outcome (adjusted OR, 1.08; 95% CI, 0.82–1.41).

Conclusions

Our study shows that high level and an increase in D‐dimer between baseline and 90 days are associated with poor outcomes in patients after ischemic stroke or transient ischemic attack.

Search for Reliable Circulating Biomarkers to Predict Carotid Plaque Vulnerability

Atherosclerosis is responsible for 20% of ischemic strokes, and the plaques from the internal carotid artery the most frequently involved. Lipoproteins play a key role in carotid atherosclerosis since lipid accumulation contributes to plaque progression and chronic inflammation, both factors leading to plaque vulnerability. Carotid revascularization to prevent future vascular events is reasonable in some patients with high-grade carotid stenosis. However, the degree of stenosis alone is not sufficient to decide upon the best clinical management in some situations. In this context, it is essential to further characterize plaque vulnerability, according to specific characteristics (lipid-rich core, fibrous cap thinning, intraplaque hemorrhage). Although these features can be partly detected by imaging techniques, identifying carotid plaque vulnerability is still challenging. Therefore, the study of circulating biomarkers could provide adjunctive criteria to predict the risk of atherothrombotic stroke. In this regard, several molecules have been found altered, but reliable biomarkers have not been clearly established yet. The current review discusses the concept of vulnerable carotid plaque, and collects existing information about putative circulating biomarkers, being particularly focused on lipid-related and inflammatory molecules.

Plasma MMP-9 and TIMP-1 levels on ICU admission are associated with 30-day survival

Background

Matrix metalloproteinases (MMPs) are involved in systemic inflammatory responses and organ failure. The aim of this study was to evaluate early circulating plasma levels of MMP‑2, MMP‑9 and their inhibitors TIMP‑1 and TIMP‑2 and their prognostic significance in critically ill patients on admission to the intensive care unit (ICU).

Methods

In a single center prospective study 120 consecutive patients (72.5% male, mean age 66.8 ± 13.3 years, mean simplified acute physiology score [SAPS II] score 52.9 ± 21.9) were enrolled on transfer to the ICU of a cardiology department. The most common underlying conditions were cardiac diseases (n = 42.5%), respiratory failure (n = 10.8%) and sepsis (n = 6.7%). Blood samples were taken within 12 h of ICU admission. The MMP‑2, MMP‑9, TIMP‑1 and TIMP‑2 levels in plasma were evaluated in terms of 30-day survival, underlying condition and clinical score.

Results

On ICU admission 30-day survivors had significantly lower plasma MMP‑9 (odds ratio, OR 1.67 per 1 SD; 95% confidence interval, CI 1.10−2.53; p = 0.016) and TIMP‑1 (OR 2.15 per 1 SD; 95% CI 1.27−3.64; p = 0.004) levels than non-survivors; furthermore, MMP‑9 and TIMP‑1 correlated well with SAPS II (both p < 0.01). In patients with underlying cardiac diseases, MMP‑9 (p = 0.002) and TIMP‑1 (p = 0.01) were independent predictors of survival (Cox regression). No significant correlation was found between MMP‑2 and TIMP‑2 levels, MMP/TIMP ratios and 30-day mortality.

Conclusion

The MMP‑9 and TIMP‑1 levels are significantly elevated in acute critical care settings with increased short-term mortality risk, especially in patients with underlying heart disease. These findings support the value of MMPs and TIMPs as prognostic markers and potential therapeutic targets in conditions leading to systemic inflammation and acute organ failure.

Blood biomarkers for physical recovery in ischemic stroke: a systematic review

Stroke is a common cause of physical disability. Biomarkers have been used to predict prognosis in ischemic stroke, but studies linking biomarkers to physical recovery from ischemic stroke have not been systematically evaluated since 2011. The purpose of this paper is to report the findings of a systematic review of the intervening literature to identify potential predictive biomarkers for recovery of physical function following ischemic stroke. The PubMed, Embase, and CINAHL databases were searched for studies reported between January 1, 2011, and September 18, 2018. Search criteria were adult ischemic stroke patients, blood sample collection within 24 ± 6 hrs of stroke onset, and outcome measures, including physical function. Identified from 18 studies and representing four biological classifications, 34 biomarkers were significantly associated with physical recovery after ischemic stroke: (1) immune response (15, 44%); (2) lipids/metabolism (4, 12%); (3) neuronal function (4, 12%); and (4) blood vessel/circulation (11, 32%). Of the predictive biomarkers associated with 1-month recovery, 60% (6 of 10) was classified into blood vessel/circulation; 54% (14 of 26) of the biomarkers associated with 3-6 month physical recovery involved the immune response. Blood biomarkers might provide useful information to improve the prediction of physical outcome after ischemic stroke. The data suggest that biomarkers from four biological classifications may predict physical recovery in patients after ischemic stroke.

Elevation of high-sensitivity cardiac troponin T at admission is associated with increased 3-month mortality in acute ischemic stroke patients treated with thrombolysis

Background

Elevated levels of cardiac troponin T (cTnT) have been associated with unfavorable outcomes in cardiac patients. However, no studies, to date, have discussed the prognostic value of high‐sensitivity cTnT (hs‐cTnT) in thrombolyzed patients with acute ischemic stroke (AIS).

Hypothesis

We hypothesized that elevated levels of hs‐cTnT would be associated with poorer clinical outcomes in AIS patients treated with intravenous tissue‐type plasminogen activator (IV tPA).

Methods

From January 2017 to February 2018, a total of 241 AIS patients treated with IV tPA within 4.5 hours of onset were recruited. On admission, patients were stratified into either normal or elevated hs‐cTnT groups according to a cutoff value of 14 ng/L. Multivariable logistic regression analyses were conducted to identify determinants of hs‐cTnT elevation and to detect whether elevated hs‐cTnT was associated with disability and/or mortality.

Results

In multivariable regression analysis, older age (P < .001) and stroke etiology (P = .024) were significantly associated with elevated hs‐cTnT levels. After adjusting for demographic and clinical characteristics, hs‐cTnT elevation was still significantly associated with 14‐day major disability (modified Rankin Scale (mRS) 3‐5, model 1, P = .019, odds ratio [OR] 2.677; model 2, P = .015, OR 2.834), 14‐day composite unfavorable outcome (mRS 3‐6, model 1, P = .005, OR 3.525; model 2, P = .003, OR 3.976), 30‐day mortality (P = .049, OR 4.545) and 90‐day mortality (P = .049, OR 3.835).

Conclusions

Elevation of hs‐cTnT at admission is associated with an increased risk of 90‐day mortality in AIS patients treated with IV tPA.

Can Admission BNP Level Predict Outcome After Intravenous Thrombolysis in Acute Ischemic Stroke?

OBJECTIVE

Our study aimed to determine the prognostic value of elevated Brain Natriuretic Peptide (BNP) among patients who received intravenous thrombolysis (IVT) in acute ischemic stroke (AIS).

BACKGROUND

The elevation in BNP level is correlated with infarct size, poststroke mortality, and CHADS2 score. Currently, there is a lack of validated biomarker to predict the outcome in patients with acute ischemic stroke, and there is a complex interaction amongst multiple variables.

DESIGN/METHODS

A retrospective review of medical records of patients admitted to our institution with acute ischemic stroke was performed. The patients who received intravenous thrombolysis were selected for analysis and divided into 2 groups based on the level of BNP. We compared the baseline demographics, past medical history, stroke etiology, discharge disposition, and 3-month mRS between both groups. Multivariate logistic regression analysis was performed to identify the predictors of poor outcome following intravenous thrombolysis in acute ischemic stroke.

RESULTS

A total of 90 patients were recruited in the study; 53 patients were found to have an elevated BNP (high BNP was defined as >100 pg/mL) level, whereas 37 had low BNP levels. Our study showed that patients with elevated BNP were more likely to have an elevation in admission and discharge NIHSS, serum creatinine, left atrial size, and blood glucose (P<0.05). Atrial fibrillation and cardioembolic strokes were seen most often in the population with elevated BNP (P<0.05). The patients with elevated BNP were less likely to be discharged home, and 3-month mRS was found to be higher, but these were not significant. On multivariate analysis, elevated BNP was not found to be an independent factor for poor outcome.

CONCLUSIONS

Elevated BNP level was not found to be an independent marker of poor outcome in AIS patients following IVT.

Expression of S100β protein in patients with vascular dementia after basal ganglia hemorrhage and its clinical significance

We investigated the expression levels and clinical significance of S100β protein in patients with vascular dementia (VD) after basal ganglia hemorrhage. From June 2014 to December 2015, in 138 patients with basal ganglia hemorrhage, we carried out the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) in patients on the day before the operation, the day after the operation and 9 days after the operation. Thirty-two patients (blood vessel group) had cognitive dysfunction and 106 patients (control group) had VD. One hundred thirty-eight cases of healthy adult volunteers were treated in Henan Provincial People's Hospital and were selected in the same period as healthy controls. The expression levels of serum S100β in the three groups were tested through the ELISA method and the statistical analysis was carried out. In VD patients, the serum S100β levels of patients were significantly higher than VD and healthy control groups; differences were statistically significant (P<0.05). However, there was no significant difference between those without VD after operation and the healthy control group (P>0.05). The correlation analysis was carried out with serum S100β as an independent variable and mean arterial pressure, BMI, MMSE and MoCA scores as dependent variables. Our results suggest that S100β expression levels were negatively correlated to the MMSE score (rs=-4.19) and the difference was statistically significant (P<0.05). The length of hospital stay of patients with basal ganglia hemorrhage associated with VD was significantly extended, with a mean of 23.4±2.8 days. The expression levels of S100β protein in the serum of patients with VD after basal ganglia hemorrhage was significantly increased and negatively correlated to the cognitive function of patients. Therefore, it can be used as a differential diagnosis indicator of VD after the basal ganglia hemorrhage and treatment target point of the VD.