Plasma Lipid Mediators Associate With Clinical Outcome After Successful Endovascular Thrombectomy in Patients With Acute Ischemic Stroke

Proteomic analysis of jugular venous blood in acute large vessel occlusion stroke with futile recanalization

Futile recanalization (FR) after endovascular treatment (EVT) remains a significant challenge for acute ischemic stroke (AIS) with large vessel occlusion (LVO). The pathogenesis of FR has not been well elucidated. We prospectively enrolled anterior circulation LVO-AIS patients who achieved successful recanalization after EVT. The jugular venous blood ipsilateral to stroke was collected before and immediately after recanalization. Plasma proteomic analysis based on liquid chromatography-mass spectrometry was performed using data-independent acquisition method. Differentially expressed proteins (DEPs) among patients with or without FR in the whole or propensity score matching (PSM) cohorts were screened according to the absolute value of fold change ≥1.5 and P value <0.05. We identified 104 and 34 DEPs between patients with or without FR in the whole cohort and PSM cohort, respectively. Bioinformatic analysis indicated that the identified proteins were primarily related to specific biological processes including immune response, complement activation, oxidative stress, lipid metabolism, protein ubiquitylation as well as autophagy, suggesting that these may be mechanisms in FR pathogenesis. Collectively, we discovered proteins that may be potential research targets for FR. The combination of proteomic and bioinformatic analysis could provide a better understanding of the pathogenesis of FR in a comprehensive manner.

Effects of elevated remnant cholesterol on outcomes of acute ischemic stroke patients receiving mechanical thrombectomy

OBJECTIVE

Large cohort studies provided evidence that elevated remnant cholesterol (RC) was an important risk factor for ischemic stroke. However, the association between high RC and clinical outcomes in acute ischemic stroke (AIS) individuals was still undetermined.

METHODS

This retrospective study enrolled 165 AIS patients undergoing mechanical thrombectomy in one tertiary stroke center. We divided patients into two groups based on the median of their RC levels (0.49 mmol/L). The modified Rankin Scale (mRS) was used to evaluate the primary outcome 90 days after the onset of symptoms. The mRS scores ≤ 2 and ≤ 1 at 90 days were deemed as favorable and excellent outcomes, respectively.

RESULTS

In the overall AIS patients undergoing mechanical thrombectomy, there was no obvious distinction between the high and low RC group at 90-day favorable outcome (41.0% vs. 47.1%, P = 0.431) or excellent outcome (23.1% vs. 31.0%, P = 0.252). In the subgroup analysis stratified by stroke etiology, non-large artery atherosclerosis (non-LAA) stroke patients yielded with less favorable or excellent prognosis in the high RC group (26.8% vs. 46.8%, adjusted OR = 0.31, 95%CI: 0.11-0.85, P = 0.023; or 12.2% vs. 29.0%, adjusted OR = 0.18, 95%CI: 0.04-0.80, P = 0.024, respectively.). Post hoc power analyses indicated that the power was sufficient for favorable outcome (80.38%) and excellent outcome (88.72%) in non-LAA stroke patients. Additionally, RC can enhance the risk prediction value of a poor outcome (mRS scores 3-6) based on traditional risk indicators (including age, initial NIHSS score, operative duration, and neutrophil-to-lymphocyte ratio) for non-LAA stroke patients (AUC = 0.86, 95%CI: 0.79-0.94, P < 0.001).

CONCLUSION

In AIS patients undergoing mechanical thrombectomy, elevated RC was independently related to poor outcome for non-LAA stroke patients, but not to short-term prognosis of LAA stroke patients.

Serum resolvin D1 potentially predicts neurofunctional recovery, the risk of recurrence and death in patients with acute ischemic stroke

Resolvin D1 (RvD1) represses inflammation, oxidative damage and neural injury related to acute ischemic stroke (AIS) progression. The present study aimed to explore the association of serum RvD1 with disease features, neurological recovery and prognosis in patients with AIS. A total of 212 patients with newly diagnosed AIS, whose serum RvD1 was quantified at admission and at discharge using an ELISA were enrolled in the current study. The modified Rankin scale (mRS) score was noted at 3 months after patient enrolment (M3), and patients were followed up for a median duration of 11.4 (range, 1.1-21.0) months. The median RvD1 in patients with AIS at admission was 1.07 (range, 0.11-9.29) ng/ml and it was negatively correlated with the neutrophil/lymphocyte ratio (r=-0.160; P=0.009) and C-reactive protein level (r=-0.272; P<0.001), but it was not correlated with comorbidities or other biochemical indexes. RvD1 at admission was lower in patients with mRS >2 at M3 (P=0.001), recurrence (P=0.001) or death (P=0.032) compared with that in patients without the aforementioned characteristics, which had a general ability to estimate mRS >2 at M3 [area under curve (AUC), 0.633], as well as lower risk of recurrence (AUC, 0.745) and death (AUC, 0.757) according to receiver operator characteristic (ROC) curve analyses. The median RvD1 was raised to 1.70 (range, 0.30-16.62) ng/ml at discharge. RvD1 at discharge was able to forecast mRS >2 at M3 (AUC, 0.678) and was able to predict the risk of recurrence (AUC, 0.796) and death (AUC, 0.826) in the ROC curve analyses. Increased serum RvD1 was associated with an attenuated inflammation status, and predicted improved neurological recovery, and lower risk of recurrence and death in patients with AIS. More specifically, its level at discharge exhibits a better prognostic utility than that at admission.

Glyceryl triacetate promotes blood-brain barrier recovery after ischemic stroke through lipogenesis-mediated IL-33 in mice

BACKGROUND

Lipid metabolism has a crucial role in neural repair in neurodegenerative diseases. We recently revealed that lipogenesis-mediated interleukin-33 (IL-33) upregulation lead to blood-brain barrier (BBB) repair after ischemic stroke. However, manipulating the key enzyme fatty acid synthase (FASN) to enhance lipogenesis was very challenging. Glyceryl triacetate (GTA) was used as a donor of acetate and precursor of acetyl coenzyme A, the key substrate for de novo lipogenesis catalyzed by FASN. Therefore, we hypothesized that GTA would promote lipogenesis the peri-infarct after ischemic stroke and contribute to the BBB repair through IL-33.

METHODS

Middle cerebral artery occlusion (MCAO) was performed on C57BL mice and GTA was gavage administrated (4 g/kg) on day 2 and 4 after MCAO. Lipogenesis was evaluated by assessment of the protein level of FASN, lipid droplets, and fatty acid products through liquid chromatography-mass spectrometry in the peri-infarct area on day 3 after MCAO, respectively. BBB permeability was determined by extravasation of Evans blue, IgG and dextran, and levels of tight junction proteins in the peri-infarct area on day 7 after MCAO, respectively. Infarct size and neurological defects were assessed on day 7 after MCAO. Brain atrophy on day 30 and long-term sensorimotor abilities after MCAO were analyzed as well. The inhibitor of FASN, C75 and the virus-delivered FASN shRNA were used to evaluate the role of FASN-driven lipogenesis in GTA-improved BBB repair. Finally, the therapeutic potential of recombinant IL-33 on BBB repair and neurological recovery was evaluated.

RESULTS

We found that treatment with GTA increased the lipogenesis as evidenced by lipid droplets level and lauric acid content, but not the FASN protein level. Treatment with GTA increased the IL-33 level in the peri-infarct area and decreased the BBB permeability after MCAO. However, infarct size and neurological defect score were unchanged on day 7 after MCAO, while the long-term recovery of sensorimotor function and brain atrophy were improved by GTA. Inhibition of lipogenesis using C75 or FASN shRNA reversed the beneficial effect of GTA. Finally, exogenous IL-33 improved BBB repair and long-term functional recovery after stroke.

CONCLUSION

Collectively, we concluded that treatment with GTA improved the BBB repair and functional recovery after ischemic stroke, probably by the enhancement of lipogenesis and IL-33 expression.

Declined Serum Resolvin D1 Levels to Predict Severity and Prognosis of Human Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study

Background

Resolvin D1 (RvD1) possesses anti-inflammatory properties and may be neuroprotective. This study was designed to ascertain the potential role of serum RvD1 in the evaluation of aSAH severity and prognosis of human aneurysmal subarachnoid hemorrhage (aSAH).

Methods

In this prospective observational study, serum RvD1 levels were measured in 123 patients with aSAH and in 123 healthy volunteers. Six-month neurological function was assessed using extended Glasgow outcome scale (GOSE). A prognostic prediction model was appraised using a series of evaluative tools, such as a nomogram, receiver operating characteristic (ROC) curve, decision curve, calibration curve, restricted cubic spline, and Hosmer-Lemeshow goodness of fit statistics.

Results

Serum RvD1 levels were markedly lower in patients than in controls (median, 0.54 versus 1.47 ng/mL; P<0.001). Serum RvD1 levels were independently correlated with Hunt-Hess scores (beta, -0.154; 95% confidence interval [CI], -0.198--0.109; VIF, 1.769; P=0.001), modified Fisher scores (beta, -0.066; 95% CI, -0.125--0.006; VIF, 1.567; P=0.031) and 6-month GOSE scores (beta, 1.864; 95% CI, 0.759-2.970; VIF, 1.911; P=0.001) and were independently predictive of a poor prognosis (GOSE scores of 1-4) (odds ratio, 0.137; 95% CI, 0.023-0.817; P=0.029). Serum RvD1 levels significantly distinguished the risk of a worse prognosis, with an area under the ROC curve of 0.750 (95% CI, 0.664-0.824). Using the Youden method, serum RvD1 levels < 0.6 ng/mL was effective in predicting worse prognosis with 84.1% sensitivity and 62.0% specificity. Moreover, the model containing serum RvD1 levels, Hunt-Hess scores and modified Fisher scores was efficient, reliable and beneficial in prognostic prediction using a series of the afore-mentioned evaluative tools.

Conclusion

A decline in serum RvD1 levels following aSAH is closely correlated with illness severity and independently predicts a worse outcome in patients with aSAH, implying that serum RvD1, as a prognostic biomarker of aSAH, may be of clinical value in aSAH.

Prognostic significance of serum resolvin D1 levels in patients with acute supratentorial intracerebral hemorrhage: a prospective longitudinal cohort study

OBJECTIVE

Resolvin D1 (RvD1) has anti-inflammatory properties and may be neuroprotective. This study was designed to assess usability of serum RvD1 as a prognostic biomarker after intracerebral hemorrhage (ICH).

METHODS

In this prospective, observational study of 135 patients and 135 controls, serum RvD1 levels were measured. Its relations to severity, early neurologic deterioration (END) and poststroke 6-month worse outcome (modified Rankin Scale scores of 3-6) were determined via multivariate analysis. Predictive effectiveness was evaluated based on area under receiver operating characteristic curve (AUC).

RESULTS

Patients had markedly lower serum RvD1 levels than controls (median, 0.69 ng/ml versus 2.15 ng/ml). Serum RvD1 levels were independently correlated with the National Institutes of Health Stroke Scale (NIHSS) [β, -0.036; 95% confidence interval (CI), -0.060--0.013; VIF, 2.633; t=-3.025; P=0.003] and hematoma volume (β, -0.019; 95% CI, -0.056--0.009; VIF, 1.688; t=-2.703; P=0.008). Serum RvD1 levels substantially discriminated risks of END and worse outcome with AUCs at 0.762 (95% CI, 0.681-0.831) and 0.783 (95% CI, 0.704-0.850) respectively. A RvD1 cut-off value of 0.85 ng/ml was effective in predicting END with a sensitivity of 95.0% and specificity of 48.4% and its levels <0.77 ng/ml distinguished patients at risk of worse outcome with a sensitivity of 84.5% and specificity of 63.6%. Under restricted cubic spline, serum RvD1 levels were linearly related to risk of END and worse outcome (both P>0.05). Serum RvD1 levels and NIHSS scores independently predicted END with odds ratio (OR) values of 0.082 (95% CI, 0.010-0.687) and 1.280 (95% CI, 1.084-1.513) respectively. Serum RvD1 levels (OR, 0.075; 95% CI, 0.011-0.521), hematoma volume (OR, 1.084; 95% CI, 1.035-1.135) and NIHSS scores (OR, 1.240; 95% CI, 1.060-1.452) were independently associated with worse outcome. END prediction model containing serum RvD1 levels and NIHSS scores, and prognostic prediction model containing serum RvD1 levels, hematoma volumes and NIHSS scores displayed efficient predictive ability with AUCs at 0.828 (95% CI, 0.754-0.888) and 0.873 (95% CI, 0.805-0.924) respectively. Such two models were visually shown via building two nomograms. Using Hosmer-Lemeshow test, calibration curve and decision curve, the models were comparatively stable and had clinical benefit.

CONCLUSION

There is a dramatical declination of serum RvD1 levels after ICH, which is tightly related to stroke severity and is independently predictive of poor clinical outcome, implying that serum RvD1 may be of clinical significance as a prognostic marker of ICH.

Longitudinal Change of Serum Inter-α-Trypsin Inhibitor Heavy Chain H4 and its Relation with Inflammation, Disease Recurrence, and Mortality in Acute Ischemic Stroke Patients

Inter-α-trypsin inhibitor heavy chain H4 (ITIH4) modulates atherosclerosis, lipid, and inflammation, which is involved in the development of acute ischemic stroke. Hence, this study aimed to investigate the longitudinal change and prognostic role of ITIH4 in acute ischemic stroke. In 267 patients with acute ischemic stroke, serum ITIH4 after admission (baseline), the 1st day after admission (D1), D3, D7, and D30, and inflammatory cytokines at baseline were detected by enzyme-linked immunosorbent assay (ELISA). Additionally, serum ITIH4 of 30 controls after enrollment was detected by ELISA. ITIH4 was reduced in acute ischemic stroke patients than controls [median (interquartile range, IQR): 131.0 (95.5-194.3) vs. 418.6 (241.5-506.8) ng/mL] (P < 0.001). Among acute ischemic stroke patients, ITIH4 was negatively associated with tumor necrosis factor-alpha (r = -0.211, P = 0.001), interleukin (IL)-1β (r = -0.164, P = 0.007), IL-6 (r = -0.121, P = 0.049), and IL-17A (r = -0.188, P = 0.002). ITIH4 presented a decreased trend from admission to D3, then increased from D3 to D30 (P < 0.001). The 1-year, 2-year, and 3-year cumulative recurrence rate was 7.5%, 18.0%, and 19.1%, respectively; meanwhile, 1-year, 2-year, and 3-year cumulative death rate was 2.2%, 7.1%, and 7.1%, accordingly. The further analysis presented that ITIH4 at baseline (P = 0.002), D1 (P = 0.049), D3 (P = 0.003), D7 (P < 0.001), and D30 (P < 0.001) was decreased in recurrent patients than non-recurrent patients; besides, ITIH4 at D3 (P = 0.017), D7 (P = 0.004), and D30 (P = 0.002), but not at baseline (P = 0.151) or D1 (P = 0.013), was decreased in deaths than survivors. Serum ITIH4 declines at first and then elevates with time, and its reduction is correlated with higher inflammation, increased risk of recurrence and mortality in acute ischemic stroke patients.

Smoking Affects the Post-Stroke Inflammatory Response of Lipid Mediators in a Gender-Related Manner

The main goal of our study was to determine the effect of cigarette smoking on selected derivatives of arachidonic acid, linoleic acid, DHA, and EPA, which may be markers of post-stroke inflammation. The eicosanoid profile was compared in both smoking and non-smoking patients, without division and with division into gender. In the group of non-smokers, we observed higher levels of the linolenic acid derivative (LA) 9S HODE (p ≤ 0.05) than in smokers. However, after dividing the results by sex, it turned out that the level of this derivative was higher in non-smoking women compared to smoking women (p ≤ 0.01) and did not differentiate the group of men. Similarly, the level of the arachidonic acid metabolite LTX A4 (p ≤ 0.05) differed only in the group of women. In this group, we also observed a decreased level of 15S HETE in smoking women, but it was statistically insignificant (p ≤ 0.08). On the other hand, the level of this derivative was statistically significantly higher in the group of non-smoking women compared to male non-smokers. The group of men was differentiated by two compounds: TXB2 and NPD1. Male smokers had an almost two-fold elevation of TXB2 (p ≤ 0.01) compared with non-smokers, and in this group, we also observed an increased level of NPD1 compared with male non-smokers. On the other hand, when comparing female non-smokers and male non-smokers, in addition to the difference in 15S HETE levels, we also observed elevated levels of TXB2 in the group of non-smokers. We also analyzed a number of statistically significant correlations between the analyzed groups. Generally, men and women smokers showed a much smaller amount of statistically significant correlations than non-smokers. We believe that this is related to the varying degrees of inflammation associated with acute ischemic stroke and post-stroke response. On the one hand, tobacco smoke inhibits the activity of enzymes responsible for the conversion of fatty acids, but on the other hand, it can cause the failure of the inflammatory system, which is also the body's defense mechanism. Smoking cigarettes is a factor that increases oxidative stress even before the occurrence of a stroke incident, and at the same time accelerates it and inhibits post-stroke repair mechanisms. This study highlights the effect of smoking on inflammation in both genders mediated by lipid mediators, which makes smoking cessation undeniable.

Receptor for Advanced Glycation End Product, Organ Crosstalk, and Pathomechanism Targets for Comprehensive Molecular Therapeutics in Diabetic Ischemic Stroke

Diabetes mellitus, a well-established risk factor for stroke, is related to higher mortality and poorer outcomes following the stroke event. Advanced glycation end products(AGEs), their receptors RAGEs, other ligands, and several other processes contribute to the cerebrovascular pathomechanism interaction in the diabetes-ischemic stroke combination. Critical reappraisal of molecular targets and therapeutic agents to mitigate them is required to identify key elements for therapeutic interventions that may improve patient outcomes. This scoping review maps evidence on the key roles of AGEs, RAGEs, other ligands such as Leukotriene B4 (LTB4), High-mobility group box 1 (HMGB1) nuclear protein, brain-kidney-muscle crosstalk, alternate pathomechanisms in neurodegeneration, and cognitive decline related to diabetic ischemic stroke. RAGE, HMGB1, nitric oxide, and polyamine mechanisms are important therapeutic targets, inflicting common consequences of neuroinflammation and oxidative stress. Experimental findings on a number of existing-emerging therapeutic agents and natural compounds against key targets are promising. The lack of large clinical trials with adequate follow-up periods is a gap that requires addressing to validate the emerging therapeutic agents. Five therapeutic components, which include agents to mitigate the AGE-RAGE axis, improved biomarkers for risk stratification, better renal dysfunction management, adjunctive anti-inflammatory-antioxidant therapies, and innovative neuromuscular stimulation for rehabilitation, are identified. A comprehensive therapeutic strategy that features all the identified components is needed for outcome improvement in diabetic stroke patients.

Comparison of predictors of failure of early neurological improvement after successful endovascular treatment for posterior and anterior circulation large vessel occlusion: Data from ANGEL-ACT registry

PURPOSE

To identify and compare the predictors of failure of early neurological improvement (fENI)after successful EVT for anterior circulation large vessel occlusion (ACLVO) and posterior circulation LVO (PCLVO).

METHODS

Subjects were selected from the ANGEL-ACT registry. fENI was defined as unchanged or worsened in National Institutes of Health Stroke Scale score (NIHSS) between admission and 24 h after EVT. Predictors of fENI after successful EVT (mTICI 2b-3) were determined via center-adjusted analyses. Univariable and multivariable comparisons between ACLVO and PCLVO were performed.

RESULTS

A total of 1447 patients, 1128 were with ACLVO, and 319 were with PCLVO. Among the patients with ACLVO, there were 409 patients (36.3%) with fENI and 719 patients (63.7%) with ENI. We observed that pre-stroke mRS scale score of 2 (odd ratio[OR] 95% confidence interval[CI], 6.93[1.99-24.10], P = 0.002), initial NIHSS score (OR per point[95%CI], 0.97[0.95-0.99], P = 0.012), diabetes (OR[95%CI], 1.56[1.08-2.25], P = 0.017), previous ICH (OR[95%CI] 9.21[1.76-48.15], P = 0.008), local anesthesia (OR[95%CI] 1.63[1.10-2.42], P = 0.014), onset-to-puncture time (OR[95%CI], 1.001[1.000-1.001], P = 0.009), symptomatic ICH (OR[95%CI] 3.90[2.27-6.69], P < 0.001), and continued use of tirofiban within 2 h after EVT (OR[95%CI], 0.69[0.51-0.93], P = 0.014) were independent predictors of fENI of ACLVO after EVT. Among the patients with PCLVO, there were 112 patients (35.1%) with fENI and 207 patients (64.9%) with ENI. In contrast, admission SBP (OR[95%CI], 0.98[0.97-0.99], P = 0.012), and vascular dissection within 2 h after EVT (OR[95%CI], 7.23[1.33-39.13], P = 0.022) were independent predictors of fENI of PCLVO after EVT.

CONCLUSION

In selected patients, successful EVT can lead to similar outcomes in PCLVO and ACLVO. Some predictors of fENI in both anterior circulation and posterior circulation were identified in our study, which should be highly considered in the clinical practice in LVO patients undergoing EVT.