C-reactive Protein, Infection, and Outcome After Acute Ischemic Stroke: A Registry and Systematic Review

The impact of dysbiosis in oropharyngeal and gut microbiota on systemic inflammatory response and short-term prognosis in acute ischemic stroke with preceding infection

Background

Stroke is a devastating disease and ranks as the second leading cause of death and disability globally. Several studies have shown that preceding infection (PI) of upper respiratory tract are strongly associated with acute ischemic stroke (AIS). However, the clinical implications and underlying pathological mechanisms remain unclear.

Methods

In this study, 16S rRNA gene sequencing was employed to compare the structural characteristics of oropharyngeal and gut microbiota in AIS patients with or without PI and normal controls (NCs; 30 cases each), and systemic inflammatory markers were detected to explore the relationship between upper respiratory tract infections (URTIs) and subsequent stroke severity and functional outcome and the potential mechanism.

Results

We found that patients with AIS-PI exhibited elevated serum WBC, NE, CRP, and Hcy levels, as well as a higher 90-day mRS score. Oropharyngeal and gut microbiota analysis showed that AIS and AIS-PI patients exhibited increased microbial richness in sequence. Principal coordinate analysis of the microbiota demonstrated significant differences in microbiota composition among the three groups. In AIS-PI patients, Megamonas, Megasphaera, Ruminococcaceae UCG 004, Rothia, and Streptococcus were significantly enriched in the gut. Opportunistic pathogens, including Thermus, uncultured Veillonella sp., and Oribacterium sinu, were found to be significantly enriched in the oropharynx. The dysregulated microbiota were positively correlated with systemic inflammatory markers, stroke severity, and poor prognosis. In contrast, short-chain fatty acid-producing bacteria Eisenbergiella, bacterium NLAE, Fusicatenibacter, Ruminococcaceae, and Faecalibacterium were enriched in NCs. Their abundances were negatively correlated with systemic inflammatory markers, stroke severity and poor prognosis.

Conclusion

Our findings suggest that PIs of the upper respiratory tract may contribute to poor short-term functional outcome in AIS patients by causing disturbance of the oropharyngeal and gut microbiota and promoting elevated systemic inflammation levels.

Genetics of ischemic stroke functional outcome

Ischemic stroke, which accounts for 87% of cerebrovascular accidents, is responsible for massive global burden both in terms of economic cost and personal hardship. Many stroke survivors face long-term disability-a phenotype associated with an increasing number of genetic variants. While clinical variables such as stroke severity greatly impact recovery, genetic polymorphisms linked to functional outcome may offer physicians a unique opportunity to deliver personalized care based on their patient's genetic makeup, leading to improved outcomes. A comprehensive catalogue of the variants at play is required for such an approach. In this review, we compile and describe the polymorphisms associated with outcome scores such as modified Rankin Scale and Barthel Index. Our search identified 74 known genetic polymorphisms spread across 48 features associated with various poststroke disability metrics. The known variants span diverse biological systems and are related to inflammation, vascular homeostasis, growth factors, metabolism, the p53 regulatory pathway, and mitochondrial variation. Understanding how these variants influence functional outcome may be helpful in maximizing poststroke recovery.

Using a k-means clustering to identify novel phenotypes of acute ischemic stroke and development of its Clinlabomics models

Objective

Acute ischemic stroke (AIS) is a heterogeneous condition. To stratify the heterogeneity, identify novel phenotypes, and develop Clinlabomics models of phenotypes that can conduct more personalized treatments for AIS.

Methods

In a retrospective analysis, consecutive AIS and non-AIS inpatients were enrolled. An unsupervised k-means clustering algorithm was used to classify AIS patients into distinct novel phenotypes. Besides, the intergroup comparisons across the phenotypes were performed in clinical and laboratory data. Next, the least absolute shrinkage and selection operator (LASSO) algorithm was used to select essential variables. In addition, Clinlabomics predictive models of phenotypes were established by a support vector machines (SVM) classifier. We used the area under curve (AUC), accuracy, sensitivity, and specificity to evaluate the performance of the models.

Results

Of the three derived phenotypes in 909 AIS patients [median age 64 (IQR: 17) years, 69% male], in phenotype 1 (N = 401), patients were relatively young and obese and had significantly elevated levels of lipids. Phenotype 2 (N = 463) was associated with abnormal ion levels. Phenotype 3 (N = 45) was characterized by the highest level of inflammation, accompanied by mild multiple-organ dysfunction. The external validation cohort prospectively collected 507 AIS patients [median age 60 (IQR: 18) years, 70% male]. Phenotype characteristics were similar in the validation cohort. After LASSO analysis, Clinlabomics models of phenotype 1 and 2 were constructed by the SVM algorithm, yielding high AUC (0.977, 95% CI: 0.961-0.993 and 0.984, 95% CI: 0.971-0.997), accuracy (0.936, 95% CI: 0.922-0.956 and 0.952, 95% CI: 0.938-0.972), sensitivity (0.984, 95% CI: 0.968-0.998 and 0.958, 95% CI: 0.939-0.984), and specificity (0.892, 95% CI: 0.874-0.926 and 0.945, 95% CI: 0.923-0.969).

Conclusion

In this study, three novel phenotypes that reflected the abnormal variables of AIS patients were identified, and the Clinlabomics models of phenotypes were established, which are conducive to individualized treatments.

Correlation of Peripheral Blood Inflammatory Indicators to Prognosis After Intravenous Thrombolysis in Acute Ischemic Stroke: A Retrospective Study

Purpose

According to many previous studies, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR) and hypersensitive C-reactive protein (CRP) are commonly used as important indicators to assess the prognosis of intravenous thrombolysis in AIS patients. Based on this, we used two novel biomarkers C-NLR (CRP/neutrophil-to-lymphocyte ratio) and C-LMR (CRP×lymphocyte-to-monocyte ratio) to investigate their correlation with 90-day outcomes in AIS patients after intravenous thrombolysis.

Patients and Methods

A total of 204 AIS patients who received intravenous thrombolysis at the Stroke Center of Jiangsu Province Hospital of Chinese Medicine from January 2021 to December 2022 were retrospectively included. All patients were followed up 90 days after thrombolysis to assess their prognosis. Patients with a modified Rankin scale score (mRS) of 3-6 were included in the unfavorable outcome group, and those with a score of 0-2 were included in the favorable outcome group. Logistic regression analysis, receiver operating characteristic (ROC) curve, and Kaplan-Meier survival curve were used to investigate the association between C-NLR, C-LMR, and 90-day prognosis in AIS patients treated with early intravenous thrombolysis.

Results

C-NLR (OR=1.586, 95% CI=1.098~2.291, P=0.014) and C-LMR (OR=1.099, 95% CI=1.025~1.179, P=0.008) were independent risk factors for 90-day prognosis of AIS patients treated with early intravenous thrombolysis. The higher C-NLR and C-LMR were associated with unfavorable prognosis.

Conclusion

C-NLR and C-LMR can be used as biomarkers to predict prognosis of AIS patients treated with early intravenous thrombolysis.

Early monitoring of intravenous thrombolysis in acute ischaemic stroke using wearable intelligent vital sign devices: protocol for a prospective, multicentre, observational registry cohort study

INTRODUCTION

Continuous monitoring of vital signs during and after ischaemic stroke was recommended by the 'Guidelines for the Early Management of Patients with Acute Ischaemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischaemic Stroke'. Vital sign data can be associated with disease conditions and prognosis, while there is limited evidence regarding continuous monitoring of vital signs during and after acute ischaemic stroke. The wearable intelligent vital sign monitoring device is small and lightweight and constantly monitors the health status during daily activities. However, wearable intelligent vital sign monitoring devices have not been widely used in clinical practice so far. Therefore, we will investigate the effectiveness and safety of wearable intelligent vital sign monitoring devices in early in-hospital management and monitoring programmes for patients with acute ischaemic stroke. This paper presents the study protocol.

METHODS AND DESIGN

This study is a prospective, multicentre, observational registry study starting from 20 March 2023 to 20 March 2025. A total of 5740 patients with acute ischaemic stroke from 10 Chinese hospitals are planned to be enrolled. Continuous vital sign data, demographics, medical history, medication history, treatments, laboratory tests, imaging scans and follow-up data will be collected. Follow-up time points were 30 days after discharge, 30 days after intravenous thrombolysis, 3 months after intravenous thrombolysis and 12 months after intravenous thrombolysis (until March 2026). The primary outcome included the evaluation of the modified Rankin Scale at 3 months, as well as the assessment of the rate of symptomatic and asymptomatic intracranial haemorrhage throughout the hospitalisation period.

ETHICS AND DISSEMINATION

This study has been approved by the Medical Ethics Committee of Xuanwu Hospital, Capital Medical University ([2022] 203). We plan to disseminate the research findings through publication in peer-reviewed scientific journals and presentations at international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300069512.

An updated review on prediction and preventive treatment of post-stroke depression

INTRODUCTION

Post-stroke depression (PSD), one of the most common complications following stroke, affects approximately one-third of stroke patients and is significantly associated with increased disability and mortality as well as decreased quality of life, which makes it an important public health concern. Treatment of PSD significantly ameliorates depressive symptoms and improves the prognosis of stroke.

AREAS COVERED

The authors discuss the critical aspects of the clinical application of prediction and preventive treatment of PSD. Then, the authors update the biological factors associated with the onset of PSD. Furthermore, they summarize the recent progress in pharmacological preventive treatment in clinical trials and propose potential treatment targets. The authors also discuss the current roadblocks in the preventive treatment of PSD. Finally, the authors put postulate potential directions for future studies so as to discover accurate predictors and provide individualized preventive treatment.

EXPERT OPINION

Sorting out high-risk PSD patients using reliable predictors will greatly assist PSD management. Indeed, some predictors not only predict the incidence of PSD but also predict prognosis, which indicates that they might also aid the development of an individualized treatment scheme. Preventive application of antidepressants may also be considered.

CRP as a potential predictor of outcome in acute ischemic stroke

Ischemic stroke is one of the major causes of death and long-term disability worldwide. C-reactive protein (CRP) as a potential biomarker for functional outcome after acute ischemic stroke remains controversial. The aim of the present study was to examine the association between the level of CRP and functional outcome of stroke. A total of 218 consecutive patients with acute ischemic stroke within 24 h after onset were recruited for the study. Poor functional outcome was defined as a modified Rankin scale score of >2 at 3 months after stroke. The retrospective analysis was performed to investigate whether CRP within 24 h after stroke is associated with poor functional outcome at 3 months. Multivariate logistic regression analysis indicated that the CRP level (odds ratio=1.146, 95%CI: 1.012-1.297, P=0.031) was an independent risk factor for poor outcome. The receiver operating characteristics curve analysis revealed that the optimal cut-off value of CRP to distinguish favorable from poor outcome was 6.34 (area under the curve=0.829, 95%CI: 0.772-0.887, P<0.001), with 68.2% sensitivity and 85.7% specificity. Spearman correlation analysis indicated that the CRP level was positively related to the baseline National Institutes of Health Stroke Scale (NIHSS) score (r=0.551, P<0.001), fasting glucose (r=0.301, P<0.001) and age (r=0.252, P<0.001). In conclusion, a high level of CRP within 24 h after onset was associated with a poor functional outcome after the acute ischemic event. The elevation of CRP may be correlated with the baseline NIHSS score, fasting glucose and age.

[Infections and inflammation in the development of stroke]

The review systematizes data on the role of infectious diseases and systemic inflammation in the pathogenesis of stroke. Various risk factors for stroke associated with pro-inflammatory reactions and their contribution to the pathogenesis of cerebrovascular pathology are analyzed. The interaction of systemic inflammation with hemostasis disturbances and clots formation, activation of autoreactive clones of cytotoxic lymphocytes, the progression of endothelial damage, and other processes is shown. Along with infection, these factors increase the risk of stroke. The key mechanisms of the pathogenesis from the development of acute or chronic inflammation to the preconditions of stroke are presented. The mechanisms of the acting of the infectious process as a trigger factor and/or medium-term or long-term risk factors of stroke are described. A separate section is devoted to the mechanisms of developing cerebrovascular diseases after COVID-19. Identifying an increased risk of stroke due to infection can be of great preventive value. Understanding of this risk by specialists followed by correction of drug therapy and rehabilitation measures can reduce the incidence of cerebrovascular complications in infectious patients.

Towards biomarkers for outcomes after pancreatic ductal adenocarcinoma and ischaemic stroke, with focus on (co)-morbidity and ageing/cellular senescence (SASKit): protocol for a prospective cohort study

INTRODUCTION

Ageing-related processes such as cellular senescence are believed to underlie the accumulation of diseases in time, causing (co)morbidity, including cancer, thromboembolism and stroke. Interfering with these processes may delay, stop or reverse morbidity. The aim of this study is to investigate the link between (co)morbidity and ageing by exploring biomarkers and molecular mechanisms of disease-triggered deterioration in patients with pancreatic ductal adenocarcinoma (PDAC) and (thromboembolic) ischaemic stroke (IS).

METHODS AND ANALYSIS

We will recruit 50 patients with PDAC, 50 patients with (thromboembolic) IS and 50 controls at Rostock University Medical Center, Germany. We will gather routine blood data, clinical performance measurements and patient-reported outcomes at up to seven points in time, alongside in-depth transcriptomics and proteomics at two of the early time points. Aiming for clinically relevant biomarkers, the primary outcome is a composite of probable sarcopenia, clinical performance (described by ECOG Performance Status for patients with PDAC and the Modified Rankin Scale for patients with stroke) and quality of life. Further outcomes cover other aspects of morbidity such as cognitive decline and of comorbidity such as vascular or cancerous events. The data analysis is comprehensive in that it includes biostatistics and machine learning, both following standard role models and additional explorative approaches. Prognostic and predictive biomarkers for interventions addressing senescence may become available if the biomarkers that we find are specifically related to ageing/cellular senescence. Similarly, diagnostic biomarkers will be explored. Our findings will require validation in independent studies, and our dataset shall be useful to validate the findings of other studies. In some of the explorative analyses, we shall include insights from systems biology modelling as well as insights from preclinical animal models. We anticipate that our detailed study protocol and data analysis plan may also guide other biomarker exploration trials.

ETHICS AND DISSEMINATION

The study was approved by the local ethics committee (Ethikkommission an der Medizinischen Fakultät der Universität Rostock, A2019-0174), registered at the German Clinical Trials Register (DRKS00021184), and results will be published following standard guidelines.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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