Monomeric C-Reactive Protein and Cerebral Hemorrhage: From Bench to Bedside

The rate-pressure product combined model within 24 h on admission predicts the 30-day mortality rate in conservatively treated patients with intracerebral hemorrhage

Background and objectives

Recently, some literature has proposed new indicators such as rate-pressure product, platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, etc. However, there has been no literature that has utilized these new indicators to establish a predictive model for assessing the risk of mortality in patients within 24 h on admission. Therefore, this study aims to build a predictive model that can rapidly assess the likelihood of mortality in patients within 24 h of admission.

Methods

The datasets used in this study are available from the corresponding author upon reasonable request. Patients were randomly assigned to the training or validation cohort based on a ratio of 7:3, which was implemented as internal validations for the final predictive models. In the training set, least absolute shrinkage and selection operator (LASSO) regression was employed to select predictive factors, followed by both univariate and subsequent multivariate analysis. The predictive ability was assessed by the area under the receiver operating characteristic (ROC) curve.

Results

A total of 428 patients were included in our research. The final model included 4 independent predictors (Glasgow Coma Scale, hematoma volume, rate-pressure product, c-reactive protein) and was developed as a simple-to-use nomogram. The training set and internal validation set model's C-index are 0.933 and 0.954, demonstrating moderate predictive ability with regard to risks of mortality. Compared to ICH score (AUC: 0.910 and 0.925), the net reclassification index (NRI) is 0.298 (CI = -0.105 to 0.701, p: 0.147) and integrated discrimination improvement (IDI) is 0.089 (CI = -0.049 to 0.228, p: 0.209). Our model is equally excellent as the classic ICH score model.

Conclusion

We developed a model with four independent risk factors to predict the mortality of ICH patients. Our predictive model is effective in assessing the risk of mortality in patients within 24 h on admission, which might be worth considering in clinical settings after further external validation.

Baseline perihematomal edema, C-reactive protein, and 30-day mortality are not associated in intracerebral hemorrhage

Background

The relationship between baseline perihematomal edema (PHE) and inflammation, and their impact on survival after intracerebral hemorrhage (ICH) are not well understood.

Objective

Assess the association between baseline PHE, baseline C-reactive protein (CRP), and early death after ICH.

Methods

Analysis of pooled data from multicenter ICH registries. We included patients presenting within 24 h of symptom onset, using multifactorial linear regression model to assess the association between CRP and edema extension distance (EED), and a multifactorial Cox regression model to assess the association between CRP, PHE volume and 30-day mortality.

Results

We included 1,034 patients. Median age was 69 (interquartile range [IQR] 59-79), median baseline ICH volume 11.5 (IQR 4.3-28.9) mL, and median baseline CRP 2.5 (IQR 1.5-7.0) mg/L. In the multifactorial analysis [adjusting for cohort, age, sex, log-ICH volume, ICH location, intraventricular hemorrhage (IVH), statin use, glucose, and systolic blood pressure], baseline log-CRP was not associated with baseline EED: for a 50% increase in CRP the difference in expected mean EED was 0.004 cm (95%CI 0.000-0.008, p = 0.055). In a further multifactorial analysis, after adjusting for key predictors of mortality, neither a 50% increase in PHE volume nor CRP were associated with higher 30-day mortality (HR 0.97; 95%CI 0.90-1.05, p = 0.51 and HR 0.98; 95%CI 0.93-1.03, p = 0.41, respectively).

Conclusion

Higher baseline CRP is not associated with higher baseline edema, which is also not associated with mortality. Edema at baseline might be driven by different pathophysiological processes with different effects on outcome.

Mendelian randomization analysis identifies a genetic casual association between circulating C-reactive protein and intracerebral hemorrhage

BACKGROUND

The causal effect of C-reactive protein (CRP) on intracerebral hemorrhage (ICH) remains controversial. We discussed the causal association of CRP with ICH based on two-sample Mendelian randomization.

METHODS

The data from two genome-wide association studies (GWAS) of European ancestry was extracted, including circulating CRP levels (204,402 individuals) and ICH (1,687 cases and 201,146 controls). The inverse variance weighted (IVW) method was primary tool to evaluate the causal relationship of circulating CRP levels on ICH risk. MR-Egger regression and MR-PRESSO global test were utilized to identify pleiotropy. Heterogeneity was discussed with Cochran's Q test. The leave-one-out analysis explored the reliability of the results.

RESULTS

54 SNPs were identified as instrumental variables (IVs) for circulating CRP levels, and these IVs had no significant horizontal pleiotropy, heterogeneity, or bias. MR analysis demonstrated a causal relationship between elevated circulating CRP levels and decreased risk of ICH (ORIVW = 0.828, 95% CI 0.692-0.992, P = 0.040).

CONCLUSION

Elevated circulating CRP levels demonstrated a significant potentially protective causal relationship with risk of ICH.

Neutrophil-to-lymphocyte ratio, white blood cell, and C-reactive protein predicts poor outcome and increased mortality in intracerebral hemorrhage patients: a meta-analysis

Objective

Inflammation participates in the pathology and progression of secondary brain injury after intracerebral hemorrhage (ICH). This meta-analysis intended to explore the prognostic role of inflammatory indexes, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), white blood cell (WBC), and C-reactive protein (CRP) in ICH patients.

Methods

Embase, PubMed, Web of Science, and Cochrane Library were searched until June 2023. Two outcomes, including poor outcome and mortality were extracted and measured. Odds ratio (OR) and 95% confidence interval (CI) were presented for outcome assessment.

Results

Forty-six studies with 25,928 patients were included in this meta-analysis. The high level of NLR [OR (95% CI): 1.20 (1.13-1.27), p < 0.001], WBC [OR (95% CI): 1.11 (1.02-1.21), p = 0.013], and CRP [OR (95% CI): 1.29 (1.08-1.54), p = 0.005] were related to poor outcome in ICH patients. Additionally, the high level of NLR [OR (95% CI): 1.06 (1.02-1.10), p = 0.001], WBC [OR (95% CI): 1.39 (1.16-1.66), p < 0.001], and CRP [OR (95% CI): 1.02 (1.01-1.04), p = 0.009] were correlated with increased mortality in ICH patients. Nevertheless, PLR was not associated with poor outcome [OR (95% CI): 1.00 (0.99-1.01), p = 0.749] or mortality [OR (95% CI): 1.00 (0.99-1.01), p = 0.750] in ICH patients. The total score of risk of bias assessed by Newcastle-Ottawa Scale criteria ranged from 7-9, which indicated the low risk of bias in the included studies. Publication bias was low, and stability assessed by sensitivity analysis was good.

Conclusion

This meta-analysis summarizes that the high level of NLR, WBC, and CRP estimates poor outcome and higher mortality in ICH patients.

C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians

The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.

Machine learning-based prediction of cerebral hemorrhage in patients with hemodialysis: A multicenter, retrospective study

Background

Intracerebral hemorrhage (ICH) is one of the most serious complications in patients with chronic kidney disease undergoing long-term hemodialysis. It has high mortality and disability rates and imposes a serious economic burden on the patient's family and society. An early prediction of ICH is essential for timely intervention and improving prognosis. This study aims to build an interpretable machine learning-based model to predict the risk of ICH in patients undergoing hemodialysis.

Methods

The clinical data of 393 patients with end-stage kidney disease undergoing hemodialysis at three different centers between August 2014 and August 2022 were retrospectively analyzed. A total of 70% of the samples were randomly selected as the training set, and the remaining 30% were used as the validation set. Five machine learning (ML) algorithms, namely, support vector machine (SVM), extreme gradient boosting (XGB), complement Naïve Bayes (CNB), K-nearest neighbor (KNN), and logistic regression (LR), were used to develop a model to predict the risk of ICH in patients with uremia undergoing long-term hemodialysis. In addition, the area under the curve (AUC) values were evaluated to compare the performance of each algorithmic model. Global and individual interpretive analyses of the model were performed using importance ranking and Shapley additive explanations (SHAP) in the training set.

Results

A total of 73 patients undergoing hemodialysis developed spontaneous ICH among the 393 patients included in the study. The AUC of SVM, CNB, KNN, LR, and XGB models in the validation dataset were 0.725 (95% CI: 0.610 ~ 0.841), 0.797 (95% CI: 0.690 ~ 0.905), 0.675 (95% CI: 0.560 ~ 0.789), 0.922 (95% CI: 0.862 ~ 0.981), and 0.979 (95% CI: 0.953 ~ 1.000), respectively. Therefore, the XGBoost model had the best performance among the five algorithms. SHAP analysis revealed that the levels of LDL, HDL, CRP, and HGB and pre-hemodialysis blood pressure were the most important factors.

Conclusion

The XGB model developed in this study can efficiently predict the risk of a cerebral hemorrhage in patients with uremia undergoing long-term hemodialysis and can help clinicians to make more individualized and rational clinical decisions. ICH events in patients undergoing maintenance hemodialysis (MHD) are associated with serum LDL, HDL, CRP, HGB, and pre-hemodialysis SBP levels.

Fueling the flames of colon cancer – does CRP play a direct pro-inflammatory role?

Background

Systemic inflammation, diagnostically ascribed by measuring serum levels of the acute phase reactant C-reactive protein (CRP), has consistently been correlated with poor outcomes across cancer types. CRP exists in two structurally and functionally distinct isoforms, circulating pentameric CRP (pCRP) and the highly pro-inflammatory monomeric isoform (mCRP). The aim of this pilot study was to map the pattern of mCRP distribution in a previously immunologically well-defined colon cancer (CC) cohort and explore possible functional roles of mCRP within the tumor microenvironment (TME).

Methods

Formalin-fixed, paraffin-embedded (FFPE) tissue samples from 43 stage II and III CC patients, including 20 patients with serum CRP 0-1 mg/L and 23 patients with serum CRP &gt;30 mg/L were immunohistochemically (IHC) stained with a conformation-specific mCRP antibody and selected immune and stromal markers. A digital analysis algorithm was developed for evaluating mCRP distribution within the primary tumors and adjacent normal colon mucosa.

Results

mCRP was abundantly present within tumors from patients with high serum CRP (&gt;30 mg/L) diagnostically interpreted as being systemically inflamed, whereas patients with CRP 0-1 mg/L exhibited only modest mCRP positivity (median mCRP per area 5.07‰ (95%CI:1.32-6.85) vs. 0.02‰ (95%CI:0.01-0.04), p&lt;0.001). Similarly, tissue-expressed mCRP correlated strongly with circulating pCRP (Spearman correlation 0.81, p&lt;0.001). Importantly, mCRP was detected exclusively within tumors, whereas adjacent normal colon mucosa showed no mCRP expression. Double IHC staining revealed colocalization of mCRP with endothelial cells and neutrophils. Intriguingly, some tumor cells also colocalized with mCRP, suggesting a direct interaction or mCRP expression by the tumor itself.

Conclusion

Our data show that the pro-inflammatory mCRP isoform is expressed in the TME of CC, primarily in patients with high systemic pCRP values. This strengthens the hypothesis that CRP might not only be an inflammatory marker but also an active mediator within tumors.

Exercise modulation in inflammation and metabolic hormonal disorders of COVID-19 to decrease risk factors in coronary heart disease

OBJECTIVES

Sedentary life style separated during COVID-19 pandemic. Patients with cardiovascular diseases (CVD) are vulnerable with sedentary life style. Therefore, the aim of this study was to investigate the effect of 8 weeks of combined and high intensity interval training (HIIT) on C Reactive protein, galectin-3, leptin, fibrinogen and insulin resistance index in coronary heart disease after COVID-19.

METHODS

Thirty-six cardiovascular patients (55.14 ± 1.4 years, 78.6 ± 5.1 kg) were divided into three groups of combined exercise (n=13), HIIT (n=12) and control group (n=11). Combined exercise consisted of aerobic (4 weeks) and aerobic + HIIT exercise (4 weeks), three sessions per weeks. The protocol of the HIIT group included performing high intensity interval training, three sessions per weeks for 8 weeks. Blood samples were taken 24 h before the first training session and 48 h after the last training. C Reactive protein (CRP), galectin-3, leptin, fibrinogen measured with ELISA kit.

RESULTS

CRP, galectin-3 and fibrinogen decreased significantly after 8 weeks of combined training and HIIT (compare to pre-test). Also, insulin resistance index after 8 weeks of combined exercise showed a significant decrease compare to pre-test (p<0.05). After 8 weeks, CRP, galectin-3 and insulin resistance significantly decreased compare to control group (p<0.05).

CONCLUSIONS

In the patient with CVD, combined exercise training may be more effective than HIIT in reducing metabolic and heart risk factors after an epidemic such as COVID-19. However, change of leptin need to more studies.

Elevation of C-reactive protein in adolescent bipolar disorder vs. anxiety disorders

Bipolar disorder (BD) largely begins in adolescence, but diagnosis lags for years, causing significant morbidity and mortality, and demonstrating the need for better diagnostic tools. Suggesting an association between BD and immune activity, elevated levels of peripheral inflammatory markers, including C-reactive protein (CRP), have been found in adults with BD. As similar data are extremely limited in adolescents, this study examined CRP levels in adolescents with BD (n = 37) compared to those with anxiety disorders (ADs, n = 157) and healthy controls with no psychiatric diagnoses (HCs, n = 2760). CRP blood levels for patients aged 12-17 years were retrieved from a nationwide repository of deidentified clinical data. After excluding patients with inflammatory conditions, differences in CRP were examined using multivariate and weighted regressions (covariates: demographics and BMI). Mean CRP levels were significantly elevated in adolescents with BD relative to those with ADs and HCs. Mean CRP levels were lower in the ADs cohort versus HCs. Although CRP levels were significantly higher in males and younger patients, the significant between-cohort differences in CRP remained after controlling for multiple confounders. To our knowledge, our study is the first to compare CRP levels between adolescent BD, ADs, and HCs, comprising a novel and essential contribution. Our results suggest the presence of a unique immune process in adolescents with BD and indicate that CRP may represent a biomarker with a crucial role in the diagnostic assessment of adolescent BD.

Relationship between CRP gene polymorphisms and ischemic stroke risk: A systematic review and meta-analysis

Ischemic stroke (IS), usually caused due to an abrupt blockage of an artery, is the leading cause of disability and the second leading cause of death worldwide. The association of the C-reactive protein (CRP) gene (s3093059 T/C and rs1205 C/T) polymorphisms and IS susceptibility has been widely studied, but the results remain inconsistent. Our study aimed to assess the association between CRP gene (s3093059 T/C and rs1205 C/T) polymorphisms and IS risk. PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, and WanFang databases were searched up to April 2022 to identify eligible studies. The Newcastle-Ottawa scale (NOS) score was calculated to assess study quality. The odd ratios (ORs) with a 95% confidence interval (CI) were calculated to assess the association between CRP gene (rs3093059 T/C and rs1205 C/T) polymorphisms and IS risk. Eighteen case–control studies with 6339 cases and 29580 controls were identified. We found that CRP (s3093059 T/C and rs1205 C/T) polymorphism was not significantly associated with the risk of IS in any genetic model (recessive model: OR 1.00, 95% CI 0.79–1.26; OR 1.06, 95% CI 0.90–1.25). When stratified analysis by country, genotype method, source of controls, and NOS score, still no statistically significant association was found. Our study indicated that the CRP (rs3093059 T/C and rs1205 C/T) polymorphisms were not associated with the susceptibility to IS.

Glucose to Platelet Ratio: A Potential Predictor of Hemorrhagic Transformation in Patients with Acute Ischemic Stroke

Glucose and platelet are two easily obtained clinical indicators; the present research aimed to demonstrate their association with hemorrhagic transformation (HT) in acute ischemic stroke (AIS) patients without thrombolytic or thrombectomy therapy. This was a single-center retrospective study. Patients who were diagnosed with HT after AIS were included in the HT group. Meanwhile, using the propensity score matching (PSM) approach, with a ratio of 1:2, matched patients without HT were included in the non-HT group. Serum G/P levels were measured on the first morning after admission (at least eight hours after the last meal). Characteristics were compared between the two groups. Multivariate logistic regression was used to determine the independent relationship between G/P and HT after AIS, with G/P being divided into quartiles. From January 2013 to March 2022, we consecutively included 643 AIS patients with HT (426/643 [66.25%] with HI and 217/643 [33.75%] with PH), and 1282 AIS patients without HT, at the First Affiliated Hospital of Wenzhou Medical University. The HT group had higher G/P levels than the non-HT group (0.04 ± 0.02 vs. 0.03 ± 0.02, p < 0.001). However, there was no difference in G/P levels between HI and PH subgroups (0.04 ± 0.02 vs. 0.04 ± 0.02, p > 0.05). Moreover, the G/P levels were divided into quartiles (Q1 ≤ 0.022; Q2 = 0.023−0.028; Q3 = 0.029−0.039; Q4 ≥ 0.040), with Q1 being settled as the reference layer. After controlling the confounders, multivariate regression analyses showed that the Q4 layer (Q4: G/P ≥ 0.040) was independently associated with elevated HT risk (odds ratio [OR] = 1.85, 95% CI = 1.31−2.63, p < 0.001). G/P levels on admission were independently associated with HT risk in AIS patients. In clinical practice, adequate attention should be paid to AIS patients with elevated G/P levels (G/P ≥ 0.040).

Neutrophil to lymphocyte ratio predicting poor outcome after aneurysmal subarachnoid hemorrhage: A retrospective study and updated meta-analysis

Background

The relationship between neutrophil to lymphocyte ratio (NLR) and poor outcome of aneurysmal subarachnoid hemorrhage (aSAH) is controversial. We aim to evaluate the relationship between NLR on admission and the poor outcome after aSAH.

Method

Part I: Retrospective analysis of aSAH patients in our center. Baseline characteristics of patients were collected and compared. Multivariate analysis was used to evaluate parameters independently related to poor outcome. Receiver operating characteristic (ROC) curve analysis was used to determine the best cut-off value of NLR. Part II: Systematic review and meta-analysis of relevant literature. Related literature was selected through the database. The pooled odds ratio (OR) and corresponding 95% confidence interval (CI) were calculated to evaluate the correlation between NLR and outcome measures.

Results

Part I: A total of 240 patients with aSAH were enrolled, and 52 patients had a poor outcome. Patients with poor outcome at 3 months had a higher admission NLR, Hunt & Hess score, Barrow Neurological Institute (BNI) scale score, Subarachnoid Hemorrhage Early Brain Edema Score (SEBES), and proportion of hypertension history. After adjustment, NLR at admission remained an independent predictor of poor outcome in aSAH patients (OR 0.76, 95% CI 0.69-0.83; P < 0.001). The best cut-off value of NLR in ROC analysis is 12.03 (area under the curve 0.805, 95% CI 0.735 - 0.875; P < 0.001). Part II: A total of 16 literature were included. Pooled results showed that elevated NLR was significantly associated with poor outcome (OR 1.31, 95% CI 1.14-1.49; P < 0.0001) and delayed cerebral ischemia (DCI) occurrence (OR 1.32, 95% CI 1.11-1.56; P = 0.002). The results are more reliable in large sample sizes, low NLR cut-off value, multicenter, or prospective studies.

Conclusion

Elevated NLR is an independent predictor of poor outcome and DCI occurrence in aSAH.

An exploratory analysis of biomarkers of perihematomal edema in the CN-105 in participants with acute supratentorial intracerebral hemorrhage (CATCH) trial

OBJECTIVE

To identify biomarkers with potential to indicate severity of perihematomal edema and secondary tissue injury after intracerebral hemorrhage (ICH), and which could be used as surrogate markers in future clinical trials for novel ICH therapeutics.

MATERIALS AND METHODS

This exploratory cohort study compared trends in neuroinflammatory biomarker levels in 18 consecutively enrolled patients with acute supratentorial ICH and 16 patients treated with the investigational neuroprotective therapy CN-105 to identify a panel of 10 biomarkers. Biomarker levels over five days post-hemorrhage were then compared with edema volumes in a larger sample of patients treated with CN-105.

RESULTS

Mean normalized edema volumes increased over time; higher CRP levels were associated with increased edema volumes (p = 0.006, r = 0.56). Higher IL8, IL10, MCP, and MMP-9 levels were associated with decreased edema volumes (p = 0.005, r =-0.57; p = 0.02, r =-0.51; p = 0.02, r =-0.52; p = .002, r =-0.63, respectively). IL1-RA, IL1-B, IL23, vWF, and IL17 levels were not significantly associated with edema volumes (p > 0.05).

CONCLUSIONS

This exploratory study provides some of the first insights into the longitudinal associations between markers of neuroinflammation and development of perihematomal edema and secondary tissue injury in human ICH. We hypothesize that these biomarkers could be used as surrogates for treatment effect in novel therapies intended to limit neuroinflammation after ICH.

Consistency Analysis of 3 Detection Systems for Measuring Serum C-Reactive Protein

BACKGROUND C-reactive protein (CRP) is an important clinical indicator. There are many methods and instruments for CRP measurement, and therefore the consistency of CRP values measured between instruments needs to be evaluated. This study aimed to compare the consistency of 3 serum CRP detection systems using turbidimetry. MATERIAL AND METHODS The consistency of CRP measured by 3 instruments, the Mindray BC-5390, Mindray BC-6800, and Johnson Vitros5600, was evaluated, and the consistency of blood routine measurement between the BC-5390 and BC-6800 was also evaluated. Pearson correlation analysis was used to evaluate the correlation of different instrument's test results (R, correlation coefficient). The consistency of instruments was assessed by Passing-Bablok analysis and weighted Deming analysis. RESULTS CRP data and route blood test data from 847 patients were used for analysis. The results showed that there were differences in the CRP values measured by the Mindray BC5390, Mindray BC6800, and Johnson Vitros5600 (χ²=78.573, P<0.001). The CRP measurement results of the BC5390 analyzer were consistent with those of the BC6800 analyzer (R=0.994, P<0.001) and Vitros5600 analyzer (R=0.983, P<0.001). However, there was a constant deviation in the CRP values measured by the BC-6800 and Vitros5600 analyzer (R=0.994, P<0.001). In the measurement of routine blood laboratory tests, the BC5390 analyzer and BC6800 analyzer were found to be interchangeable. CONCLUSIONS This study analyzed the consistency of CRP detection by 3 instruments, the Mindray BC-5390, Mindray BC-6800, and Johnson Vitros5600, and may provide a reference for the selection of CRP detection instruments.

Correlation of Immune-Inflammatory Markers with Clinical Features and Novel Location-Specific Nomograms for Short-Term Outcomes in Patients with Intracerebral Hemorrhage

(1) Background: We investigated the association of four immune-inflammatory markers with clinical features and established location-specific nomograms to predict mortality risk in patients with intracerebral hemorrhage (ICH). (2) Methods: We retrospectively enrolled 613 inpatients with acute ICH. (3) Results: Overall mortality was 22%, which was highest in pontine hemorrhage and lowest in thalamic hemorrhage. All four immune-inflammatory markers exhibited a positive linear correlation with glucose, ICH volume, ICH score, and discharge Modified Rankin Scale (mRS) score. Significant predictors of death due to lobar/putaminal hemorrhage were age, glucose and creatinine levels, initial Glasgow Coma Scale (GCS) score, ICH volume, and presence of intraventricular hemorrhage. None of the immune-inflammatory markers were significant predictors of unfavorable outcome or death. We selected significant factors to establish nomograms for predicting death due to lobar/putaminal, thalamic, pontine, and cerebellar hemorrhages. The C-statistic for predicting death in model I (comprising factors in the establishment of the nomogram) in each type of ICH was higher than that in model II (comprising ICH score alone), except for cerebellar hemorrhage. These nomograms for predicting death had good discrimination (C-index: 0.889 to 0.975) and prediction probabilities (C-index: 0.890 to 0.965). (4) Conclusions: Higher immune-inflammatory markers were associated with larger ICH volume, worse initial GCS, and unfavorable outcomes, but were not independent prognostic predictors. The location-specific nomograms provided novel and accurate models for predicting mortality risk.

Prognostic Significance of the Combined Score of Plasma Fibrinogen and Neutrophil-Lymphocyte Ratio in Patients with Spontaneous Intracerebral Hemorrhage

Background

The combination of plasma fibrinogen and neutrophil to lymphocyte ratio (F-NLR) score is a novel inflammatory marker constituted by peripheral blood fibrinogen concentration and neutrophil to lymphocyte ratio. In the current study, we aim to explore the relationship between admission F-NLR score and intracerebral hemorrhage (ICH) and assess its prognostic predictive ability in ICH patients.

Methods

The original cohort was consecutively recruited from August 2014 to September 2017, and the validation cohort was consecutively recruited between October 2018 and March 2020. The primary outcomes were 3-month functional outcome and 1-month mortality. All statistical analyses were performed using SPSS and R software.

Results

A total of 431 and 251 ICH patients were included in original cohort and validation cohort, respectively. In the original cohort, F-NLR score could independently predict the 3-month functional outcome (adjusted OR 2.013, 95% CI 1.316-3.078, p = 0.001) and 1-month mortality (adjusted OR 3.036, 95% CI 1.965-4.693, p < 0.001). Receiver operation characteristic (ROC) analyses and predictive model comparison indicated that F-NLR score had a stronger predictive ability in the 3-month outcome and 1-month mortality. Validation cohort verified the results.

Conclusion

F-NLR score was an independent indicator for both the 3-month functional outcome and 1-month mortality, and its prognostic predictive ability was superior to fibrinogen and NLR in both the original and the validation cohort.

Potential Biomarkers for Post-Stroke Cognitive Impairment: A Systematic Review and Meta-Analysis

Stroke is a primary debilitating disease in adults, occurring in 15 million individuals each year and causing high mortality and disability rates. The latest estimate revealed that stroke is currently the second leading cause of death worldwide. Post-stroke cognitive impairment (PSCI), one of the major complications after stroke, is frequently underdiagnosed. However, stroke has been reported to increase the risk of cognitive impairment by at least five to eight times. In recent decades, peripheral blood molecular biomarkers for stroke have emerged as diagnostic, prognostic, and therapeutic targets. In this study, we aimed to evaluate some blood-derived proteins for stroke, especially related to brain damage and cognitive impairments, by conducting a systematic review and meta-analysis and discussing the possibility of these proteins as biomarkers for PSCI. Articles published before 26 July 2021 were searched in PubMed, Embase, the Web of Science, and the Cochrane Library to identify all relevant studies reporting blood biomarkers in patients with stroke. Among 1820 articles, 40 were finally identified for this study. We meta-analyzed eight peripheral biomarker candidates: homocysteine (Hcy), high-density lipoprotein cholesterol (HDL-C), C-reactive protein (CRP), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglyceride (TG), uric acid, and glycated hemoglobin (HbA1c). The Hcy, CRP, TC, and LDL-C levels were significantly higher in patients with PSCI than in the non-PSCI group; however, the HDL-C, TG, uric acid, and HbA1c levels were not different between the two groups. Based on our findings, we suggest the Hcy, CRP, TC, and LDL-C as possible biomarkers in patients with post-stroke cognitive impairment. Thus, certain blood proteins could be suggested as effective biomarkers for PSCI.

Emergency department point‑of‑care biomarkers and day 90 functional outcome in spontaneous intracerebral hemorrhage: A single‑center pilot study

Spontaneous intracerebral hemorrhage (sICH) results in high morbidity and mortality rates, thus identifying strategies for timely prognosis and treatment is important. The present study aimed to analyze the relationship between emergency department point-of-care (POC) blood biomarkers and day 90 functional outcome (FO) in patients with acute (<8 h) sICH. On-site POC determinations, including complete blood count, glucose, cardiac troponin I, D-dimer and C-reactive protein, and derived inflammatory indexes were performed for a cohort of 35 patients. The primary endpoint was a favorable day 90 FO (modified Rankin Score ≤3). Secondary endpoints included early neurological worsening (ENW), day 7/discharge neurological impairment, day 90 independence assessment (Barthel Index <60), hematoma enlargement and perihematomal edema (PHE) growth. A favorable three-month FO was reported in 16 (46%) participants. Older age, previous history of ischemic stroke and initial imagistic parameters, including intraventricular hemorrhage, enlarged contralateral ventricle and cerebral atrophy, significantly predicted an unfavorable FO. The admission D-dimer similarly predicted day 90 FO and the independence status, along with ENW and a more severe day 7/discharge neurological status. The D-dimer also correlated with the initial neurological status and PHE. PHE growth correlated with granulocytes, systemic immune-inflammation index and glycemia. The results suggested that a lower admission D-dimer could indicate an improved day 90 FO of patients with sICH, while also anticipating the development of PHE growth and ENW.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early neutrophil-to-lymphocyte ratio is a prognostic marker in acute minor stroke or transient ischemic attack

Intravenous injection of alteplase is recommended for patients with minor disabling and not non-disabling ischemic stroke symptoms within 4.5 h of ischemic stroke symptom onset. However, it is hard for clinicians to distinguish which type of minor ischemic stroke is disabled at an early stage. In this study, we aimed to demonstrate early neutrophil-to-lymphocyte ratio is a prognostic marker in acute minor stroke or transient ischemic attack. 196 patients diagnosed with acute minor stroke or transient ischemic attack within 24 h of symptom onset were enrolled. Patients were divided into three groups according to the neutrophil-to-lymphocyte ratio value (< 2, 2-3, > 3). Clinical, neuroradiological, laboratory and follow-up data were collected from electronic database. Functional outcome was assessed by modified Rankin Scale. Neutrophil-to-lymphocyte ratio associated with functional outcome of 90 days was evaluated by logistic regression analysis, and we used receiver operating characteristic curve analysis to detect the overall predictive accuracy of this marker. Early neutrophil-to-lymphocyte ratio was associated with an increased risk of short-term functional outcome (OR 4.502, 95% CI 1.533-13.046, P = 0.006). The optimal cutoff value of neutrophil-to-lymphocyte ratio for prediction of short-term unfavorable outcome was 2.94 with a sensitivity of 69.6% and a specificity of 77.1% (area under the curve: 0.767, 95% CI 0.691-0.843). Early neutrophil-to-lymphocyte ratio is associated with short-term unfavorable functional outcome in patients with acute minor stroke or transient ischemic attack. Early neutrophil-to-lymphocyte ratio is beneficial for clinicians to distinguish minor disabling ischemic stroke at an early stage.

C-Reaction Protein and the Severity of Intracerebral Hemorrhage: A Study from Chinese Stroke Center Alliance

BACKGROUND

Intracerebral hemorrhage (ICH) has a high mortality and morbidity in the world. C-Reaction Protein (CRP) has been demonstrated to be an independent risk factor and could predict the severity and outcome of ischemic stroke. In our study, we aimed to find out the relationship between CRP levels and the severity and outcome of patients with ICH.

METHODS

This study comes from the Chinese Stroke Center Alliance (CSCA). Patients' basic characteristics and laboratory examination results, including the concentration of CRP were taken from August 2015 to July 2019. Chi-square test and Logistic regression were used to analyze the relationship between different CRP levels and clinical outcome.

RESULTS

A total of 9589 patients with acute ICH were enrolled in our study. In the logistic regression analysis, we found out that high CRP level is an independent risk factor for the prevalence of severe ICH and in-hospital death. After adjusting sex, age and other relevant stroke risk factors, the difference still exists (Severe ICH: odd ratio (OR) (95% confidence interval (CI) = 1.14 (1.04-1.26), P = 0.0076 for CRP between 3-10mg/l group and 1.64 (1.46-1.84), P<0.0001 for CRP>10mg/l group. In-hospital death: OR(95%CI)= 2.03(1.39-2.95), P=0.0002 for CRP>10mg/l group).

CONCLUSIONS

High CRP level was independently associated with poorer clinical outcome and higher in-hospital death in patients with ICH.

Emerging pathogenic role of peripheral blood factors following BBB disruption in neurodegenerative disease

The responses of central nervous system (CNS) cells such as neurons and glia in neurodegenerative diseases (NDs) suggest that regulation of neuronal and glial functions could be a strategy for ND prevention and/or treatment. However, attempts to develop such therapeutics for NDs have been hindered by the challenge of blood-brain barrier (BBB) permeability and continued constitutive neuronal loss. These limitations indicate the need for additional perspectives for the prevention/treatment of NDs. In particular, the disruption of the blood-brain barrier (BBB) that accompanies NDs allows brain infiltration by peripheral factors, which may stimulate innate immune responses involved in the progression of neurodegeneration. The accumulation of blood factors like thrombin, fibrinogen, c-reactive protein (CRP) and complement components in the brain has been observed in NDs and may activate the innate immune system in the CNS. Thus, strengthening the integrity of the BBB may enhance its protective role to attenuate ND progression and functional loss. In this review, we describe the innate immune system in the CNS and the contribution of blood factors to the role of the CNS immune system in neurodegeneration and neuroprotection.

Protocatechuic Acid Suppresses Microglia Activation and Facilitates M1 to M2 Phenotype Switching in Intracerebral Hemorrhage Mice

OBJECTIVES

Microglia activation, a key process in secondary injury following intracerebral hemorrhage (ICH), is divided to M1 and M2 phenotype. Protocatechuic acid (PCA) is a phenolic acid been proved neuroprotection in ICH without understanding of details. Thus, this study aimed to observe the influence of PCA on microglia activation and explore underlying mechanisms.

MATERIALS AND METHODS

To assess PCA affected microglia activation in vivo, an experimental ICH mice model was established and then treated with PCA intraperitoneal injection. Immunofluorescence staining was performed in brain slices at day 3 post ICH. BV2 cells were stimulated with hemin for activation, then M1 and M2 biomarkers were analyzed using Western Blot and qPCR. At last, we detected the expression of mTOR and its downstream molecules to discuss possible mechanisms.

RESULTS

At day 3 post ICH, less activated microglia gathering around hematoma after PCA treatment. Furtherly, in hemin treated BV2 cells, PCA downregulated M1 and promoted M2 biomarkers expression in both mRNA and protein level. PCA inhibited the phosphorylation of mTOR, S6K1 and 4E-BP1, while the inhibition was disappeared after supplemented with mTOR activator.

CONCLUSIONS

PCA impacted microglia activation by suppressing the mTOR signaling pathway, thereby improving M1/M2 switch and attenuated neuroinflammation.

Systemic inflammation status at admission affects the outcome of intracerebral hemorrhage by increasing perihematomal edema but not the hematoma growth

Acute stress and inflammation responses are associated with worse outcomes in intracerebral hemorrhage (ICH) but the precise mechanisms involved are unclear. We evaluated the effect of neutrophil-to-lymphocyte ratio (NLR) in ICH outcome, with focus on hematoma expansion and early cerebral edema. In a retrospective study, we included all patients with primary ICH admitted to our center within 24-h from symptom onset from January 2014 to February 2015. We retrieved demographic and medical history data, Glasgow Coma Scale scores, blood cell counts, glucose, and C-reactive protein, and calculated NLR. We obtained hematoma volumes by computerized planimetry. Outcomes included independence at 90 days (modified Rankin scale 0-2), mortality at 30 days, significant hematoma expansion (> 33% or > 6 mL) and early cerebral edema causing significant midline shift (> 2.5 mm) at 24 h. We included 135 patients. NLR independently associated with independence at 90 days (adjusted odds ratio (aOR) 0.79, 95% CI 0.67-0.93, p = 0.006) significant cerebral edema (aOR 1.08, 95%CI 1.01-1.15, p = 0.016) but not hematoma expansion (aOR 0.99, 95%CI 0.94-1.04, p = 0.736). The severity of midline shift was positively correlated with NLR (adjusted beta = 0.08, 95% CI 0.05-0.11, p < 0.001). In ICH, an immediate and intense systemic inflammatory response reduces the likelihood of a better functional outcome at 90 days, which is more likely to be explained by perihematomal edema growth than due to a significant hematoma expansion. These findings could have implications in new treatment strategies and trial designs, which endpoints tend to target exclusively hematoma enlargement.

Local Experimental Intracerebral Hemorrhage in Rats

(1) Background: Hemorrhagic stroke is a lethal disease, accounting for 15% of all stroke cases. However, there are very few models of stroke with a hemorrhagic etiology. Research work is devoted to studying the development of cerebrovascular disorders in rats with an intracerebral hematoma model. The aim of this study was to conduct a comprehensive short-term study, including neurological tests, biochemical blood tests, and histomorphological studies of brain structures. (2) Methods: The model was reproduced surgically by traumatizing the brain in the capsula interna area and then injecting autologous blood. Neurological deficit was assessed according to the McGrow stroke-index scale, motor activity, orientation–exploratory behavior, emotionality, and motor functions. On Day 15, after the operation, hematological and biochemical blood tests as well as histological studies of the brain were performed. (3) Results: The overall lethality of the model was 43.7%. Acute intracerebral hematoma in rats causes marked disorders of motor activity and functional impairment, as well as inflammatory processes in the nervous tissue, which persist for at least 14 days. (4) Conclusions: This model reflects the situation observed in the clinic and reproduces the main diagnostic criteria for acute disorders of cerebral circulation.

Rupture Risk of Intracranial Aneurysm and Prediction of Hemorrhagic Stroke after Liver Transplant

Postoperative hemorrhagic stroke (HS) is a rare yet devastating complication after liver transplantation (LT). Unruptured intracranial aneurysm (UIA) may contribute to HS; however, related data are limited. We investigated UIA prevalence and aneurysmal subarachnoid hemorrhage (SAH) and HS incidence post-LT. We identified risk factors for 1-year HS and constructed a prediction model. This study included 3544 patients who underwent LT from January 2008 to February 2019. Primary outcomes were incidence of SAH, HS, and mortality within 1-year post-LT. Propensity score matching (PSM) analysis and Cox proportional hazard analysis were performed. The prevalence of UIAs was 4.63% (n = 164; 95% confidence interval (CI), 3.95–5.39%). The 1-year SAH incidence was 0.68% (95% CI, 0.02–3.79%) in patients with UIA. SAH and HS incidence and mortality were not different between those with and without UIA before and after PSM. Cirrhosis severity, thrombocytopenia, inflammation, and history of SAH were identified as risk factors for 1-year HS. UIA presence was not a risk factor for SAH, HS, or mortality in cirrhotic patients post-LT. Given the fatal impact of HS, a simple scoring system was constructed to predict 1-year HS risk. These results enable clinical risk stratification of LT recipients with UIA and help assess perioperative HS risk before LT.

Pre-exposure of voglibose exerts cerebroprotective effects through attenuating activation of the polyol pathway and inflammation

Chronic hyperglycemia induces activation of the polyol-sorbitol pathway, which is a major contributor to microvascular complications like stroke. The current study was designed to elucidate the therapeutic role of α-glucose inhibitor in chronic hyperglycemia-induced impaired polyol pathway and associated micro-complications. Male albino-Wistar rats (200-250 g) were treated with voglibose 10 mg kg^-1  day^-1 /p.o. for 2 weeks before middle cerebral artery occlusion; 72 hr after surgery, neurological score was evaluated and blood was collected for the assessment of various serum biochemical parameters like CRP, CK-MB, LDH, lipid profile, and blood glucose levels. In the end, brain samples were excised for determination of brain infarct volume, brain hemisphere weight difference, Na+-K+ ATPase activity oxidative stress-related parameters, aldose reductase activity, and gene expression studies. Results from the present study indicate that pre-treatment with voglibose showed significant improvement in lipid parameters but did not impact glucose levels. Voglibose has shown a statistically significant (p < .05) reduction in neurological score and brain infarct volume, and the difference in brain hemisphere weight as compared to the disease control group. Voglibose significantly (p < .05) improve all biochemical parameters and reduced Na+-K+ ATPase and aldose reductase activity. Moreover, voglibose produced a significant reduction in oxidative stress and down-regulation of TNF-α and BCl-2 gene expression which reduces the risk of factors related to stroke. In conclusion, the pleiotropic effect of voglibose on cerebrovascular complications may be due to inhibition of aldose reductase or anti-inflammatory pathways.

A nomogram to predict early hematoma expansion of hypertensive cerebral hemorrhage

Early hematoma expansion of hypertensive cerebral hemorrhage is affected by various factors. This study aimed to clarify the risk factors and develop a nomogram to predict early hematoma expansion.A retrospective analysis was carried out in patients with hypertensive cerebral hemorrhage admitted to our institution between January 1, 2012 and December 31, 2018; the patients were divided into 2 groups according to the presence of early hematoma expansion. Univariate and multivariate analyses were performed to analyze the risk factors of hematoma expansion. The nomogram was developed based on a multivariate logistic regression model, and the discriminative ability of the model was analyzed.A total of 477 patients with hypertensive cerebral hemorrhage and with a baseline hematoma volume <30 ml were included in our retrospective analysis. The hematoma expansion rate was 34.2% (163/477). After multivariate logistic regression, 9 variables (alcohol history, Glasgow coma scale score, total serum calcium, blood glucose, international normalized ratio, hematoma shape, hematoma density, volume of hematoma on initial computed tomography scan, and presence of intraventricular hemorrhage) identified as independent predictors of hematoma expansion were used to generate the nomogram. The area under the receiver operating characteristic curve of the nomogram was 0.883 (95% confidence interval 0.851-0.914), and the cutoff score was -0.19 with sensitivity of 75.5% and specificity of 87.3%.The nomogram can accurately predict the risk of early hematoma expansion.

The physiopathology of spontaneous hemorrhagic stroke: a systematic review

Hemorrhagic stroke (HS) is a major cause of death and disability worldwide, despite being less common, it presents more aggressively and leads to more severe sequelae than ischemic stroke. There are two types of HS: Intracerebral Hemorrhage (ICH) and Subarachnoid Hemorrhage (SAH), differing not only in the site of bleeding, but also in the mechanisms responsible for acute and subacute symptoms. This is a systematic review of databases in search of works of the last five years relating to the comprehension of both kinds of HS. Sixty two articles composed the direct findings of the recent literature and were further characterized to construct the pathophysiology in the order of events. The road to the understanding of the spontaneous HS pathophysiology is far from complete. Our findings show specific and individual results relating to the natural history of the disease of ICH and SAH, presenting common and different risk factors, distinct and similar clinical manifestations at onset or later days to weeks, and possible complications for both.

Impact of Sleep Deprivation in the Neurological Intensive Care Unit: A Narrative Review

Sleep is fundamental for everyday functioning, yet it is often negatively impacted in critically ill patients by the intensive care setting. With a focus on the neurological intensive care unit (NeuroICU), this narrative review summarizes methods of measuring sleep and addresses common causes of sleep disturbance in the hospital including environmental, pharmacological, and patient-related factors. The effects of sleep deprivation on the cardiovascular, pulmonary, immune, endocrine, and neuropsychological systems are discussed, with a focus on short-term deprivation in critically ill populations. Where evidence is lacking in the literature, long-term sleep deprivation studies and the effects of sleep deprivation in healthy individuals are also referenced. Lastly, strategies for the promotion of sleep in the NeuroICU are presented.

Pre-procedural predictive factors of symptomatic intracranial hemorrhage after thrombectomy in stroke

OBJECTIVE

Symptomatic intracerebral hemorrhage (sICH) is a common complication of acute ischemic stroke (AIS) associated with limited treatments and poor outcomes. We aimed to identify predictive factors of sICH in patients with AIS following mechanical thrombectomy (MT) in a real-world setting.

METHODS

Patients with large vessel occlusion of the anterior circulation treated with MT were consecutively included in a prospective monocentric cohort. Clinical, biological, and radiological parameters were collected to identify pre-procedural predictors for sICH.

RESULTS

637 patients were included in our study. Magnetic resonance imaging was performed on most patients (86.7%). sICH occurred in 55 patients (8.6%). 428 patients (67.2%) were treated with intravenous thrombolysis. After multivariate analysis, prior use of antiplatelet therapies (odd ratio (OR) 1.84, 95% confidence interval (CI) 1.01-3.32), high C-reactive protein (OR per standard deviation (SD) increase 1.28, 95% 1.01-1.63), elevated mean arterial blood pressure (OR per 10 mmHg increase 1.22, 95% CI 1.03-1.44), hyperglycemia (OR per one SD-log increase 1.38, 95% CI 1.02-1.87), and low ASPECTS (OR per 1-point decrease 1.42, 95% CI 1.12-1.80) were found to be independent predictive factors of sICH. The pre-procedural predictors did not change when the absence of successful recanalization was considered as a covariate. Patients with strokes of unknown onset time were not especially vulnerable for sICH.

CONCLUSION

sICH after MT was associated with several pre-procedural risk factors: prior use of antiplatelet therapies, high C-reactive protein and hyperglycemia at baseline, elevated mean arterial blood pressure, and low ASPECTS.

High Uric Acid Level Predicts Early Neurological Deterioration in Intracerebral Hemorrhage

OBJECTIVE

Increased level of serum uric acid (UA) is often considered a risk factor for ischemic stroke. However, there are limited data on the association between UA and intracerebral hemorrhage (ICH). This study aimed to examine the connection between UA and early neurological deterioration (END) in patients with ICH.

METHODS

This is a prospective observational study. Patients with ICH were enrolled from January 2017 to December 2020. END was diagnosed as the Canadian Stroke Scale (CSS) score decreased ≥1 points between admission and 48 hours. UA was measured at admission. Multivariable logistic regression analysis was performed to explore the relationship between serum UA and END.

RESULTS

Of the 498 enrolled patients, 132 (26.5%) were developed with END. Patients with END had a significantly higher level of serum UA (332 vs 270 µmol/L, P < 0.001). Univariate logistic regression analysis indicated that patients with the highest quartile of UA level had an OR of 3.256 (95% CI: 1.849-5.734, P < 0.001) for END compared with those with the lowest quartile of UA level. After adjusting for major confounders, the highest UA quartile remained as an independent predictor for END (OR = 2.282, 95% CI: 1.112-4.685, P = 0.013).

CONCLUSION

Higher serum UA level was independently associated with END in patients with ICH; therefore, intervention to lower UA level may be worth considering.

Clemastine promotes recovery of neural function and suppresses neuronal apoptosis by restoring balance of pro-inflammatory mediators in an experimental model of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) represents a common acute cerebrovascular event that imparts high rates of disability. The microglia-mediated inflammatory response is a critical factor in determining cerebral damage post-ICH. Clemastine (CLM) is a histamine receptor H1 (HRH1) antagonist that has been shown to modulate the inflammatory response. However, the effects of CLM on ICH and the underlying mechanism remain to be determined. This investigation reveals that CLM resulted in reduction of cerebral hematoma volume, decreased cerebral edema and lower rates of neuronal apoptosis as well as improved behavioral scores in an acute ICH murine model. CLM treatment was noted to decrease pro-inflammatory effectors and increased anti-inflammatory effectors post-ICH. In addition, CLM reduced the deleterious effects of activated microglia on neurons in a transwell co-culture system. Our findings show that CLM likely mediates its therapeutic effect through inhibition of microglia-induced inflammatory response and apoptosis, thereby enhancing restoration of neuronal function.

Responsive Expression of MafF to β-Amyloid-Induced Oxidative Stress

The small musculoaponeurotic fibrosarcoma (sMaf) proteins MafF, MafG, and MafK are basic region leucine zipper- (bZIP-) type transcription factors and display tissue- or stimulus-specific expression patterns. As the oxidative stress reactive proteins, sMafs are implicated in various neurological disorders. In the present study, the expressions of sMafs were investigated across five databases gathering transcriptomic data from 74 Alzheimer's disease (AD) patients and 66 controls in the Gene Expression Omnibus (GEO) database. The expression of MafF was increased in the hippocampus of AD patients, which was negatively correlated with the expression of the glutamate cysteine ligase catalytic subunit (GCLC). Furthermore, MafF was significantly increased in patients with Braak stage V-VI, compared to those with Braak stage III-IV. β-Amyloid (Aβ), a strong inducer of oxidative stress, plays a crucial role in the pathogenesis of AD. The responsive expressions of sMafs to Aβ-induced oxidative stress were studied in the APP/PS1 mouse model of AD, Aβ intrahippocampal injection rats, and several human cell lines from different tissue origins. This study revealed that only the induction of MafF was accompanied with reduction of GCLC and glutathione (GSH). MafF knockdown suppressed the increase of GSH induced by Aβ. Among sMafs, MafF is the most responsive to Aβ-induced oxidative stress and might potentiate the inhibition of antioxidation. These results provide a better understanding of sMaf modulation in AD and highlight MafF as a potential therapeutic target in AD.

Predictive Factors of Hemorrhage After Thrombolysis in Patients With Acute Ischemic Stroke

Background: Ischemic stroke has a poor prognosis and brings a ponderous burden on families and society. Hemorrhagic transformation (HT) after intravenous thrombolysis can increase the mortality of patients with ischemic stroke. Thus, finding new HT biomarkers to be applicable in clinical practice is of great importance.

Methods: The related risk factors were recruited for analysis, including smoking, drinking, hyperlipidemia, diabetes, anamnesis, and pathological indicators. Moreover, the relationship between serum levels of caveolin-1, caveolin-2, and HT after rt-PA treatment were also studied.

Results: We studied 306 patients with acute ischemic stroke treated with recombinant tissue type plasminogen activator (rt-PA) within 4.5 h of symptom onset. The results showed that Age ≥68 years, smoking, Atrial fibrillation, NIHSS score before thrombolysis ≥17, and systolic pressure 2 h after thrombolysis (mmHg) ≥149 increased the risks of HT after rt-PA administration. Remarkably, the concentration of caveolin-1 (ng/mL) ≤ 0.12 and caveolin-2 (ng/mL) ≤ 0.43 in serum increased the risks of HT after rt-PA administration.

Conclusion: Knowledge on the risk factors associated with HT after rt-PA treatment may help develop treatment strategies and reduce the risk of HT. Caveolin-1 and caveolin-2 can be predictors of HT after rt-PA administration. These findings provide evidence for future further investigations aimed to validate these biomarkers.

Associations Between Levels of High-Sensitivity C-Reactive Protein and Outcome After Intracerebral Hemorrhage

Background: Patients with spontaneous intracerebral hemorrhage (ICH) have high mortality and morbidity rates; approximately one-third of patients with ICH experience hematoma expansion (HE). The spot sign is an established and validated imaging marker for HE. High-sensitivity C-reactive protein (hs-CRP) is an established laboratory marker for inflammation and secondary brain injury following ICH. Objective: To determine the association between the spot sign and hs-CRP, hematoma expansion, and clinical outcomes. Methods: Between December 2014 and September 2016, we prospectively recruited 1,964 patients with acute symptomatic ICH at 13 hospitals in Beijing, China. Next, we selected 92 patients within 24 h of the onset of symptoms from this cohort for the present study. ICH was diagnosed in the emergency room by non-contrast computed tomography (NCCT) scans. Follow-up scans were carried out within 48 h to evaluate patients for HE. Multidetector computed tomography angiography (MDCTA) was also used to identify spot signs. Blood samples were collected from each patient at admission in EDTA tubes (for plasma) or vacutainer tubes (for serum). hs-CRP values were determined by a particle-enhanced immunoturbidimetric assay in the laboratory at Beijing Tiantan Hospital, Capital Medical University. Patients were categorized into two groups according to their hs-CRP levels (hs-CRP <3 mg/L, hs-CRP ≥3 mg/L). Results: The incidences of spot sign and HE in our study cohort were 31.5 and 29.3%, respectively. Following the removal of potential confounding variables, stepwise-forward logistic regression analysis identified that an hs-CRP level ≥3 mg/L was not a significant indicator for either spot sign (p = 0.68) or HE (p = 0.07). However, an hs-CRP level ≥3 mg/L (odds ratio: 16.64, 95% confidence interval: 2.11-131.45, p = 0.008) was identified as an independent predictor of an unfavorable outcome 1 year after acute ICH. Conclusions: Our analyses identified that an hs-CRP level ≥3 mg/L was a significant indicator for an unfavorable outcome 1 year after acute ICH.

Correlation between self-perceived burden and self-management behavior in elderly stroke survivors: A longitudinal observational study

The aim of this study was to assess the levels of self-perceived burden (SPB) and self-management behavior in elderly stroke survivors during the first 3 months after acute stroke, and to explore the correlation between them.A total of 203 consecutive hospitalized elderly patients diagnosed with stroke were recruited. Self-perceived Burden Scale and Stroke Self-management Scale in 1 month (T1) and 3 months (T2) post-stroke were assessed and compared.The score of SPB in elderly stroke survivors was 28.96 ± 5.50 and 27.25 ± 6.17 at T1 and T2, respectively. Stroke self-management scale scored 165.93 ± 9.82 at T1 and 167.29 ± 10.60 at T2. In the first 3 months post-stroke, the physical burden was dominant (T1 14.73 ± 3.07, T2 14.40 ± 3.13), and the behavior of stroke symptoms and signs monitoring (T1 27.58 ± 6.56, T2 28.64 ± 6.43) and rehabilitation exercise management (T1 21.40 ± 3.28, T2 20.74 ± 3.15) was the worst. SPB was negatively correlated with self-management behavior (T1 r = -.202, T2 r = -.511).Elderly stroke survivors experienced a medium level of SPB and self-management behavior in the first 3 months post-stroke. There is a positive relationship between reduced SPB and improved self-management behavior. Addressing the characteristics and correlations as well as development of targeted interventions for SPB decreasing is beneficial to improving self-management behavior for elderly survivors.

Predicting length of stay in patients admitted to stroke rehabilitation with severe and moderate levels of functional impairments

Severe stroke patients are known to be associated with larger rehabilitation length of stay (LOS) but other factors besides severity may be contributing. We aim to identify LOS predictors within a population of mostly severe patients and analyze the impact of socioeconomic situation in functionality at admission.A retrospective observational cohort study was conducted including 172 inpatients admitted to a rehabilitation center between 2007 and 2019. Associations with LOS were examined among 30 potential predictor variables using bivariate correlations. Significantly correlated (P < .002, Bonferroni adjustment) variables were entered into 9 different multiple linear regression models.No mild participants were included, 63.37% severe and 36.63% moderate. Most significant LOS determinants were: 1) total functional independence measure (FIM) (P < .001) and hemiparesis (P = .0108) (adjusted R = 0.24), 2) cognitive FIM (P = .002) and severity (P = .001) (adjusted R = 0.22), and 3) home accessibility (P = .043) and hemiparesis (P = 0.032) (adjusted R = 0.19).Known LOS predictors (e.g., depression, ataxia) within the full stroke severities were not found significant in our dataset.Socioeconomic situation was found moderately correlated with total FIM (r = -0.32, P < .0001).When stratifying the patients' socioeconomic situation into mild, important, and severe social risk, their respective median total FIM at admission were 61.5, 50, and 41, with significant differences between the mild and important group (P < .001); also significant differences were found between mild and severe groups (P < .001).A few of the variables identified in the literature as significant predictors of LOS within the full stroke population were also significant for our dataset (National Institutes of Health Stroke Scale, FIM, home accessibility) explaining less than 25% of the LOS variance. Most of the 30 analyzed known predictors were not significant (e.g., depression, age, recurrent stroke, ataxia, orientation, verbal communication, etc) suggesting that factors outside functional, socioeconomic, medical, and demographics not included in this study (e.g., rehabilitation sessions intensity) have important influences on LOS for severe patients.Patients at mild social risk obtained significantly higher total FIM at admission than patients at important and severe social risk. The importance of socioeconomic situation has been scarcely studied in the literature in relation to functionality at admission; our results suggest that it requires to be considered.

Inflammasome Caspase-1 Activity is Elevated in Cerebrospinal Fluid After Aneurysmal Subarachnoid Hemorrhage and Predicts Functional Outcome

BACKGROUND/OBJECTIVE

Subarachnoid hemorrhage (SAH) is a devastating neurological injury, further complicated by few available methods to objectively predict outcomes. With the recent shift in focus to neuroinflammation as a potential cause of adverse outcomes following SAH, we investigated the inflammasome-derived enzyme, caspase-1, as a potential biomarker for poor functional outcome.

METHODS

SAH patients were recruited from a regional stroke referral center. Cerebrospinal fluid (CSF) samples from 18 SAH subjects were collected via an external ventricular drain and obtained as close as possible to admission (within 72 h). For control subjects, we collected CSF from 9 patients undergoing lumbar puncture with normal CSF. Caspase-1 activity was measured using commercially available luminescence assays. SAH subjects were categorized at hospital discharge into those with good outcomes (Glasgow Outcome Scale, GOS, of 4-5) and poor outcomes (GOS of 1-3).

RESULTS

CSF analysis demonstrated a nearly seven-fold increase in caspase-1 activity in SAH patients compared to controls (p < 0.0001). Within the SAH group, 10 patients (55.6%) had good outcomes and 8 patients (44.4%) had poor outcomes. Mean caspase-1 activity in the poor outcome group was approximately three-times higher than the good outcome group (p = 0.001). Caspase-1 activity was significantly correlated with GOS score (r = - 0.705, p = 0.001). Receiver operating characteristic curve analysis showed that caspase-1 activity can accurately differentiate between patients with good versus poor functional outcome (area under the curve 0.944, p = 0.002).

CONCLUSIONS

Inflammasome-derived caspase-1 activity is elevated in the CSF of SAH patients compared to controls and higher levels correlate with worse functional outcome.

Monomeric C-Reactive Protein Aggravates Secondary Degeneration after Intracerebral Haemorrhagic Stroke and May Function as a Sensor for Systemic Inflammation

BACKGROUND

We previously identified increased tissue localization of monomeric C-reactive protein (mCRP) in the infarcted cortical brain tissue of patients following ischaemic stroke. Here, we investigated the relationship of mCRP expression in haemorrhagic stroke, and additionally examined the capacity of mCRP to travel to or appear at other locations within the brain that might account for later chronic neuroinflammatory or neurodegenerative effects.

METHODS

Immunohistochemistry was performed on Formalin-fixed, paraffin-embedded archived brain tissue blocks obtained at autopsy from stroke patients and age-matched controls. We modelled mCRP migration into the brain after haemorrhagic stroke by infusing mCRP (3.5 µg) into the hippocampus of mice and localized mCRP with histological and immunohistochemistry methods.

RESULTS

On human tissue in the early stages of haemorrhage, there was no staining of mCRP. However, with increasing post-stroke survival time, mCRP immunostaining was associated with some parenchymal brain cells, some stroke-affected neurons in the surrounding areas and the lumen of large blood vessels as well as brain capillaries. Further from the peri-haematoma region, however, mCRP was detected in the lumen of micro-vessels expressing aquaporin 4 (AQP4). In the hypothalamus, we detected clusters of neurons loaded with mCRP along with scattered lipofuscin-like deposits. In the peri-haematoma region of patients, mCRP was abundantly seen adjacent to AQP4 immunoreactivity. When we stereotactically injected mCRP into the hippocampus of mice, we also observed strong expression in distant neurones of the hypothalamus as well as cortical capillaries.

CONCLUSIONS

mCRP is abundantly expressed in the brain after haemorrhagic stroke, directly impacting the pathophysiological development of the haematoma. In addition, it may have indirect effects, where the microcirculatory system appears to be able to carry it throughout the cortex as far as the hypothalamus, allowing for long-distance effects and damage through its capacity to induce inflammation and degenerate neuronal perivascular compartments.

Falling stroke rates during COVID-19 pandemic at a comprehensive stroke center

INTRODUCTION

Although there is evidence to suggest a high rate of cerebrovascular complications in patients with SARS-CoV-2 infection, anecdotal reports indicate a falling rate of new ischemic stroke diagnoses. We conducted an exploratory single-center analysis to estimate the change in number of new stroke diagnoses in our region, and evaluate the proximate reasons for this change during the COVID-19 pandemic at a tertiary care center in New Jersey.

PATIENTS AND METHODS

A Comprehensive Stroke Center prospective cohort was retrospectively analyzed for the number of stroke admissions, demographic features, and short-term outcomes 5 months prior to 3/1/2020 (pre-COVID-19), and in the 6 weeks that followed (COVID-19 period). The primary outcome was the number of new acute stroke diagnoses before and during the COVID-19 period, as well as the potential reasons for a decline in the number of new diagnoses.

RESULTS

Of the 328 included patients, 53 (16%) presented in the COVID-19 period. There was a mean fall of 38% in new stroke diagnoses (mean 1.13/day [SD 1.07] from 1.82/day [SD 1.38], p<0.01), which was related to a 59% decline in the number of daily transfers from referral centers (p<0.01), 25% fewer telestroke consultations (p=0.08), and 55% fewer patients presenting directly to our institution by private vehicle (p<0.01) and 29% fewer patients through emergency services (p=0.09). There was no significant change in the monthly number of strokes due to large vessel occlusion (LVO), however the proportion of new LVOs nearly doubled in the COVID-19 period (38% vs. 21%, p=0.01).

CONCLUSIONS

The observations at our tertiary care center corroborate anecdotal reports that the number of new stroke diagnoses is falling, which seems related to a smaller proportion of patients seeking healthcare services for milder symptoms. These preliminary data warrant validation in larger, multi-center studies.

Falling stroke rates during COVID-19 pandemic at a comprehensive stroke center

INTRODUCTION

Although there is evidence to suggest a high rate of cerebrovascular complications in patients with SARS-CoV-2 infection, anecdotal reports indicate a falling rate of new ischemic stroke diagnoses. We conducted an exploratory single-center analysis to estimate the change in number of new stroke diagnoses in our region, and evaluate the proximate reasons for this change during the COVID-19 pandemic at a tertiary care center in New Jersey.

PATIENTS AND METHODS

A Comprehensive Stroke Center prospective cohort was retrospectively analyzed for the number of stroke admissions, demographic features, and short-term outcomes 5 months prior to 3/1/2020 (pre-COVID-19), and in the 6 weeks that followed (COVID-19 period). The primary outcome was the number of new acute stroke diagnoses before and during the COVID-19 period, as well as the potential reasons for a decline in the number of new diagnoses.

RESULTS

Of the 328 included patients, 53 (16%) presented in the COVID-19 period. There was a mean fall of 38% in new stroke diagnoses (mean 1.13/day [SD 1.07] from 1.82/day [SD 1.38], p<0.01), which was related to a 59% decline in the number of daily transfers from referral centers (p<0.01), 25% fewer telestroke consultations (p=0.08), and 55% fewer patients presenting directly to our institution by private vehicle (p<0.01) and 29% fewer patients through emergency services (p=0.09). There was no significant change in the monthly number of strokes due to large vessel occlusion (LVO), however the proportion of new LVOs nearly doubled in the COVID-19 period (38% vs. 21%, p=0.01).

CONCLUSIONS

The observations at our tertiary care center corroborate anecdotal reports that the number of new stroke diagnoses is falling, which seems related to a smaller proportion of patients seeking healthcare services for milder symptoms. These preliminary data warrant validation in larger, multi-center studies.

Home-Time as a Surrogate Measure for Functional Outcome After Stroke: A Validation Study

Purpose

Home-time has been found to correlate well with modified Rankin Scale (mRS) scores in patients with stroke. This study aimed to determine its correlations in patients with different types of stroke at various time points after stroke in a non-Western population.

Methods

This study used linked data from multi-center stroke registry databases and a nationwide claims database of health insurance. Functional outcomes as measured with the modified Rankin Scale were obtained from the registry databases and home-time was derived from the claims database. Spearman correlation coefficients were used to assess the correlation between home-time and mRS scores. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of home-time in predicting good functional outcome.

Results

This study included 7959 patients hospitalized for stroke or transient ischemic attack (TIA), for whom mRS scores were available in 6809, 6694, and 4330 patients at 90, 180, and 365 days, respectively. Home-time was highly correlated with mRS scores at the three time-points in patients with ischemic (Spearman's rho -0.69 to -0.83) or hemorrhagic (Spearman's rho -0.86 to -0.88) stroke, but the correlation was only weak to moderate in those with TIA (Spearman's rho -0.32 to -0.58). Home-time predicted good functional outcome with excellent discrimination in patients with ischemic (AUCs >0.8) or hemorrhagic (AUCs >0.9) stroke but less so in those with TIA (AUCs >0.7).

Conclusion

Home-time was highly correlated with mRS scores and showed excellent discrimination in predicting good functional outcome in patients with ischemic or hemorrhagic stroke. Home-time could serve as a valid surrogate measure for functional outcome after stroke.

The study of METTL14, ALKBH5, and YTHDF2 in peripheral blood mononuclear cells from systemic lupus erythematosus

Background

This study was aimed to explore the mRNA expression of m6A “writers” (METTL3, MTEEL14, and WTAP), “erasers” (FTO and ALKBH5), and “readers” (YTHDF2) in peripheral blood mononuclear cells (PBMCs) from systemic lupus erythematosus (SLE) patients and investigate the relation between their expressions with clinical features.

Methods

In all, 54 SLE patients and 42 healthy controls (HC) were included in the current study. Quantitative reverse transcription‐polymerase chain reaction (qRT‐PCR) was used to investigate the mRNA expression of m6A “writers,” “erasers,” and “readers” in PBMCs from SLE patients and HC.

Results

Decreased mRNA expression of MTEEL14, ALKBH5, and YTHDF2 was observed in SLE patients compared with those in HC (p < .001). The decreased mRNA expression of METTL14 was associated with white blood cell count (WBC) and monocyte count (M), this decreased mRNA expression of ALKBH5 was associated with C‐reactive protein (CRP), neutrophil percentage (N%), lymphocyte percentage (L%), neutrophil–lymphocyte ratio (NLR), complement 3 (C3), and fever, and the decreased mRNA expression of YTHDF2 was associated with L%, NLR, C3, and fever. In addition, there was a positive correlation between mRNA expression of METTL14, ALKBH5, and YTHDF2 in PBMCs from SLE patients. Importantly, logistic regression analysis revealed that decreased mRNA expression of YTHDF2 was a risk factor for SLE.

Conclusion

Taken all together, our findings suggested decreased YTHDF2 that was associated with disease activity may play an important role in the pathogenesis of SLE, METTL14 and ALKBH5 may be concomitantly decreased.

Sex Dimorphisms in Ischemic Stroke: From Experimental Studies to Clinic

Sex dimorphisms are important factors that influence the outcomes after ischemic stroke, which include basic health status, cerebrovascular anatomy, hormone levels, and unique factors such as pregnancy and menopause. It is widely recognized that male and female respond differently to stroke. Women aged 45–74 years old showed a lower risk of stroke incidence compared to age-matched man. This kind of protection is lost with aging. Hence, there is increasing requirement to get a more comprehensive understanding of sex-based factors to stroke on stroke incidence, symptoms, and treatments. This review focuses on sex-specific mechanisms in response to stroke based on experimental studies and highlights recent findings in clinical studies including sex-differential evaluation and outcomes of stroke. Sex-based personalized medicine should be promising in stroke therapies.

Potential mechanisms of hemorrhagic stroke in elderly COVID-19 patients

The novel severe acute respiratory syndrome coronavirus 2 is the causative agent of coronavirus disease 2019, a new human infectious disease. While fever, cough, and respiratory distress are typical first symptoms, a fraction of those affected present instead with neurological symptoms suggestive of central nervous system compromise. This review summarizes the potential contribution of coronavirus disease 2019 to hemorrhagic stroke in the elderly and proposes possible mechanisms. Reports show that the most affected patients have underlying chronic diseases such as hypertension and diabetes, which are two key risk factors for hemorrhagic stroke. Angiotensin-converting enzyme 2 is the main host cell surface receptor interacting with the severe acute respiratory syndrome coronavirus 2 spike glycoprotein to allow viral entry and infection. We speculate that ensuing downregulation of angiotensin-converting enzyme 2 expression may compound the risk conferred by pre-existing comorbidities and critically influence the pathogenesis of hemorrhagic stroke by elevating blood pressure and impairing cerebrovascular endothelial function. Additionally, both age- and/or disease-related immune dysfunction and enhanced catecholamine release secondary to anxiety and stress may also aggravate central nervous system symptoms of severe acute respiratory syndrome coronavirus 2 infection. Thus, assessment of systemic inflammatory biomarkers and tight control of hemodynamic parameters upon admission are crucial to minimize mortality and morbidity in coronavirus disease 2019 patients with central nervous system symptoms suggestive of incipient stroke.

Pinocembrin mitigates depressive-like behaviors induced by chronic unpredictable mild stress through ameliorating neuroinflammation and apoptosis

BACKGROUND

The majority of patients with chronic fatigue have a risk of comorbidity with depression. Pinocembrin (PB) is a kind of flavonoid molecule isolated from honey and propolis and has antimicrobial, anti-inflammatory, antioxidant, and anticancer function. The purpose of the current study was to determine the possible function of PB on treatment of depression.

METHODS

A chronic unpredictable mild stress (CUMS) mouse model was established to mimic the depressive-like behaviors in vivo. The depressive-like behaviors of CUMS mice were measured by sucrose preference test (SPT), open field test (OFT), forced swim test (FST) and tail suspension test (TST). The concentration of reactive oxygen species (ROS), malondialdehyde (MDA) and the activity or superoxide dismutase (SOD) were detected by commercial kit. The inflammatory factor including interleukin (IL)-1β, tumor necrosis factor (TNF)-α, IL-10 and transforming growth factor (TGF)-β were examined.

RESULTS

We found that PB alleviated the decreasing of sucrose preference and body weight. CUMS mice significantly increased the immobility time but decreased latency to abandon in FST, increased the immobility time in TST, and reduced crossing score and rearing score in OFT, whereas these changes were reversed by PB treatment. More importantly, PB decreased the concentration of ROS and MDA, but increased the SOD activity, suggesting that it could protected against oxidative stress in CUMS mice. Interestingly, PB inhibited cell apoptosis and regulated inflammatory factors expression in hippocampus of CUMS mice. Moreover, PB activated Nrf2/HO-1 signal pathway but inhibited the phosphorylation of NF-kB.

CONCLUSIONS

In conclusion, PB mitigated CUMS-induced depressive-like behaviors through ameliorating neuroinflammation and apoptosis.

TRIAL REGISTRATION

Not Applicable.