Effect of Hyperhomocysteinemia on Clinical Outcome and Hemorrhagic Transformation After Thrombolysis in Ischemic Stroke Patients

Relationship between baseline mean platelet volume (MPV) and prognosis of patients with acute mild cerebral infarction undergoing intravenous thrombolysis with Alteplase

Objective

To investigate the relationship between baseline, mean platelet volume (MPV) and prognosis of patients with acute mild cerebral infarction undergoing intravenous thrombolysis with alteplase.

Methods

A retrospective analysis was conducted of clinical imaging and laboratory data of patients with acute mild cerebral infarction who received intravenous thrombolytic therapy with alteplase in Baoding No.1 Central Hospital between March 2018 and March 2021. According to mRS scores after three months, a total of 140 patients were divided into the good prognosis group(n=115) (mRS score

Results

Logistic regression analysis showed that 24 hour NIHSS score after thrombolysis and baseline MPV were independently correlated with 3-month prognosis. The ROC curve indicated an optimal cutoff value of 9.65 fl for MPV in predicting poor prognosis. The study also found that the increase of baseline MPV had a close bearing on the risk increase of END.

Conclusion

Baseline MPV is an independent risk factor for early neurological deterioration and three months poor prognosis in patients with acute mild cerebral infarction undergoing intravenous thrombolysis.

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Key Words

• Ischemic stroke
• Mean platelet volume
• Prognosis
• Thrombolytic therapy

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Affiliation(s)

Yanhao Wang Yanhao Wang, Department of Neurology, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China
Xiaoqing Wei Xiaoqing Wei, Department of Neurology, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China
Wei Du Wei Du, Department of Neurology, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China
Congcong Yuan Congcong Yuan, Department of Neurology, Baoding No.1 Central Hospital, Baoding 071000, Hebei, China

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Plasma Homocysteine (Hcy) Concentration Functions as a Predictive Biomarker of SPECT-Evaluated Post-Ischemic Hyperperfusion in Acute Ischemic Stroke

Introduction

Homocysteine (Hcy) concentration has been reported to be associated with ischemic stroke. In this study, we aimed to investigate the potential of plasma Hcy in the prediction of post-ischemic hyperperfusion in AIS patients, which was diagnosed with the single-photon emission computed tomography (SPECT) method.

Methods

A total of 112 ischemic stroke patients were recruited in this study. According to whether the patients were subjected to post-ischemic hyperperfusion, all recruited subjects were divided into a post-ischemic hyperperfusion (+) group (N=48) and post-ischemic hyperperfusion (-) group (N=64). The basic demographical data, clinicopathological data and laboratory biochemical data were collected and compared. Level of homocysteine (Hcy) and cystatin-C (Cys-C) and their potential as predictive biomarker are also investigated.

Results

No significant differences were spotted between the post-ischemic hyperperfusion group (+) and post-ischemic hyperperfusion (-) group in respect to the basic demographical and clinicopathological data. And the serum Hcy levels were lower in the post-ischemic hyperperfusion (+) group. Moreover, ROC analysis indicated significant relationships between Hcy levels and the onset of post-ischemic hyperperfusion.

Conclusion

In conclusion, we validated that the plasma Hcy concentration can be used as a predictive biomarker of SPECT-evaluated post-ischemic hyperperfusion in patients suffering from acute ischemic stroke.

Higher serum homocysteine levels are associated with an increased risk of hemorrhagic transformation in patients with acute ischemic stroke

BACKGROUND

Hemorrhagic transformation (HT) is a common complication of acute ischemic stroke (AIS), and may develop into parenchyma hemorrhage (PH). We aimed to investigate the association between serum homocysteine levels and HT as well as PH in all AIS patients, and in those with and without thrombolysis by subgroup analysis.

METHODS

AIS patients who were admitted within 24 h after onset were enrolled and categorized into the higher homocysteine level group (≥ 15.5 µmol/L) and the lower homocysteine level group (< 15.5 µmol/L). HT was determined by a second round of brain imaging within 7 days during hospitalization, and PH was defined as hematoma in the ischemic parenchyma. Multivariate logistic regression was used to investigate the associations between serum homocysteine levels and HT and PH, respectively.

RESULTS

Of the 427 included patients (mean age 67.35 years, 60.0% males), 56 (13.11%) developed HT and 28 (6.56%) had PH. Serum homocysteine levels were significantly associated with HT (adjusted OR 1.029, 95%CI 1.003-1.055) and PH (adjusted OR 1.041, 95%CI 1.013-1.070). The higher homocysteine group was more likely to have HT (adjusted OR 1.902, 95% CI 1.022-3.539) and PH (adjusted OR 3.073, 95% CI 1.327-7.120) than the lower homocysteine group. Subgroup analysis of patients without thrombolysis also showed the significant differences in HT (adjusted OR 2.064, 95% CI 1.043-4.082) and PH (adjusted OR 2.926, 95% CI 1.196-7.156) between the two groups.

CONCLUSION

Higher serum homocysteine levels are associated with an increased risk of HT and PH in AIS patients, especially in those without thrombolysis. Monitoring the serum homocysteine may be conducive to determining individuals at a high risk of HT.

Neuroprotective Potentials of Flavonoids: Experimental Studies and Mechanisms of Action

Neurological and neurodegenerative diseases, particularly those related to aging, are on the rise, but drug therapies are rarely curative. Functional disorders and the organic degeneration of nervous tissue often have complex causes, in which phenomena of oxidative stress, inflammation and cytotoxicity are intertwined. For these reasons, the search for natural substances that can slow down or counteract these pathologies has increased rapidly over the last two decades. In this paper, studies on the neuroprotective effects of flavonoids (especially the two most widely used, hesperidin and quercetin) on animal models of depression, neurotoxicity, Alzheimer's disease (AD) and Parkinson's disease are reviewed. The literature on these topics amounts to a few hundred publications on in vitro and in vivo models (notably in rodents) and provides us with a very detailed picture of the action mechanisms and targets of these substances. These include the decrease in enzymes that produce reactive oxygen and ferroptosis, the inhibition of mono-amine oxidases, the stimulation of the Nrf2/ARE system, the induction of brain-derived neurotrophic factor production and, in the case of AD, the prevention of amyloid-beta aggregation. The inhibition of neuroinflammatory processes has been documented as a decrease in cytokine formation (mainly TNF-alpha and IL-1beta) by microglia and astrocytes, by modulating a number of regulatory proteins such as Nf-kB and NLRP3/inflammasome. Although clinical trials on humans are still scarce, preclinical studies allow us to consider hesperidin, quercetin, and other flavonoids as very interesting and safe dietary molecules to be further investigated as complementary treatments in order to prevent neurodegenerative diseases or to moderate their deleterious effects.

Pan-Immune-Inflammatory Value Predicts the 3 Months Outcome in Acute Ischemic Stroke Patients after Intravenous Thrombolysis

BACKGROUND AND PURPOSE

Immune and inflammatory response plays a central role in the clinical outcomes of stroke. This study is aimed to explore the clinical significance of the new inflammation index named pan-immune-inflammation value (PIV) in patients with acute ischemic stroke (AIS) after intravenous thrombolysis therapy (IVT).

METHODS

Data were collected from 717 patients who received IVT at the First Affiliated Hospital of Soochow University. Baseline data were collected before intravenous thrombolysis. Multivariate logistic regression analysis was used to assess the association between PIV and 3 months clinical outcome after intravenous thrombolysis. We also used receiver operating characteristic (ROC) curves analysis to assess the discriminative ability of PIV, platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), and systemic immune-inflammation index (SII) in predicting 3 months poor outcome.

RESULTS

Of 717 patients, 182 (25.4%) patients had poor outcomes at 3 months. Patients with 3 months of poor outcome had significantly higher PIV levels compared to those with favorable outcomes [316.32 (187.42-585.67) vs. 223.80 (131.76-394.97), p < 0.001)]. After adjusting for potential confounders, the risk of 3 months of poor outcome was significantly higher among patients whose PIV fell in the third quartile (244.21-434.49) and the fourth quartile (> 434.49) than those in the first quartile (< 139.93) (OR = 1.905, 95% CI: 1.040-3.489; OR = 2.229, 95%CI: 1.229-4.044). The area under the ROC curve of PIV to predict 3 months of poor outcome was 0.607 (95%CI: 0.560-0.654; p < 0.001). The optimal cut-off values of PIV were 283.84 (59% sensitivity and 62% specificity).

CONCLUSION

The higher levels of PIV were independently associated with 3 months of poor outcomes in AIS patients receiving IVT. PIV like other inflammatory factors (PLR, NLR, and SII), can also predict adverse outcomes after IVT in AIS patients.

The predictors of death within 1 year in acute ischemic stroke patients based on machine learning

Objective

To explore the predictors of death in acute ischemic stroke (AIS) patients within 1 year based on machine learning (ML) algorithms.

Methods

This study retrospectively analyzed the clinical data of patients hospitalized and diagnosed with AIS in the Second Affiliated Hospital of Xuzhou Medical University between August 2017 and July 2019. The patients were randomly divided into training and validation sets at a ratio of 7:3, and the clinical characteristic variables of the patients were screened using univariate and multivariate logistics regression. Six ML algorithms, including logistic regression (LR), gradient boosting machine (GBM), extreme gradient boosting (XGB), random forest (RF), decision tree (DT), and naive Bayes classifier (NBC), were applied to develop models to predict death in AIS patients within 1 year. During training, a 10-fold cross-validation approach was used to validate the training set internally, and the models were interpreted using important ranking and the SHapley Additive exPlanations (SHAP) principle. The validation set was used to externally validate the models. Ultimately, the highest-performing model was selected to build a web-based calculator.

Results

Multivariate logistic regression analysis revealed that C-reactive protein (CRP), homocysteine (HCY) levels, stroke severity (SS), and the number of stroke lesions (NOS) were independent risk factors for death within 1 year in patients with AIS. The area under the curve value of the XGB model was 0.846, which was the highest among the six ML algorithms. Therefore, we built an ML network calculator (https://mlmedicine-de-stroke-de-stroke-m5pijk.streamlitapp.com/) based on XGB to predict death in AIS patients within 1 year.

Conclusions

The network calculator based on the XGB model developed in this study can help clinicians make more personalized and rational clinical decisions.

Association between the triglyceride-glucose index and carotid plaque incidence: a longitudinal study

BACKGROUND

Carotid plaque and triglyceride-glucose (TyG) index are associated with insulin resistance. However, a highly debated question is whether there is an association between the TyG index and carotid plaque incidence. Thus we performed an in-depth longitudinal study to investigate the relationship between carotid plaque occurrence and the TyG index among Chinese individuals.

METHODS

Two thousand and three hundred seventy subjects (1381 males and 989 females) were enrolled and followed up for three years. The subjects were stratified into four groups based on the quartile of the TyG index at baseline. Univariate and multivariate Cox proportional hazard models were conducted to examine the role of TyG played in the carotid plaque. The strength of association was expressed as hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

After three years of follow-up, 444 subjects were detected with newly formed carotid plaque. The overall 3-year cumulative carotid plaque incidence was 18.7%, and the risk of carotid plaque increased with elevated TyG index (p < 0.001). The Cox regression analysis showed that males (HR: 1.33, 95% CI: 1.10-1.61), and people with higher systolic blood pressure (HR:1.01, 95% CI: 1.01-1.02), lower high-density lipoprotein cholesterol (HR: 0.68, 95% CI: 0.50-0.93), diabetes (HR: 2.21, 95% CI: 1.64-2.97), and hypertension (HR:1.49, 95% CI: 1.23-1.81) had a significantly increased risk for the carotid plaque formation. Similar results remained in the sensitivity analysis.

CONCLUSIONS

The TyG index can be used as a dose-responsive indicator of carotid plaque in the Chinese population. Elderly males with dyslipidemia, diabetes, or hypertension should be more vigilant about their TyG index since they are susceptible to developing carotid plaque. Physicians are encouraged to monitor the TyG index to help identify and treat patients with carotid plaque at an early stage.

The assessment of the cardiovascular risk in rheumatoid arthritis patients on anti TNF therapy

Auto-immune rheumatic diseases are characterised by high levels of inflammation that accelerate the development of atherosclerosis, increasing the cardiovascular risk. Direct evaluation of arteries such as of intima media thickness measurement is a simple test that asesses the cerebral and cardiovascular risk. In the initial stages, an increase of the intimal media thickness can be observed. Later on, atherosclerosis (plaques), stenosis and occlusion of the arteries can be identified. Indirect evaluation of the cardiovascular risk can be performed using serological markers - fibrinogen, C reactive protein, estimated sedimentation rate, total cholesterol, low density lipoproteins and high density lipoproteins, homocysteine levels etc. The presence of certain lifestyle factors that increase the risk, such as smoking, sedentarism and associated pathologies such as obesity, diabetes, hypertension were assesed in patients with rheumatoid arthritis. The aim of the study is to prove the relationship between anti-tumor necrosis factor alpha therapy effect on the cardiovascular risk in rheumatoid arthritis patients

The Prognostic Value of Homocysteine in Acute Ischemic Stroke Patients: A Systematic Review and Meta-Analysis

Background: This comprehensive meta-analysis aimed to assess whether an increased homocysteine (Hcy) level is an independent predictor of unfavorable outcomes in acute ischemic stroke (AIS) patients.

Methods: A comprehensive literature search was conducted up to August 1, 2020 to collect studies reporting Hcy levels in AIS patients. We analyzed all the data using Review Manager 5.3 software.

Results: Seventeen studies with 15,636 AIS patients were selected for evaluation. A higher Hcy level was associated with a poorer survival outcome (OR 1.43, 95% CI: 1.25–1.63). Compared with the AIS group, Hcy levels were significantly lower in the healthy control patients, with an SMD of 5.11 and 95% CI (1.87–8.35). Analysis of the different subgroups of AIS demonstrated significant associations between high Hcy levels and survival outcomes only in Caucasian and Asian patients. Moreover, whereas high Hcy levels were closely associated with gender, B12 deficiency, smoking, and patients who received tissue plasminogen activator treatment, no significant difference was found between increased Hcy levels and age, drinking, hypertension, diabetes mellitus, and hyperlipidemia. In addition, the cut-off value (20.0 μmol/L) might be an optimum cut-off index for AIS patients in clinical practice.

Conclusion: This meta-analysis reveals that the Hcy level may serve as an independent predictor for unfavorable survival outcomes in AIS patients, particularly in Caucasian and Asian AIS patients. Further studies can be conducted to clarify this relationship.

Association Between Plasma Total Homocysteine Levels and Risk of Early Hemorrhagic Transformation in Patients with Acute Ischemic Stroke: A Hospital-Based Study

OBJECTS

In this study, we investigated the association between plasma total homocysteine(tHcy) levels and the risk of early hemorrhagic transformation(HT) in patients with acute ischemic stroke(AIS).

METHODS

Consecutive hospitalized participants who met the inclusion criteria were enrolled and grouped according to plasma tHcy levels. Participants were divided into a low homocysteine level(L-tHcy) group (<12 µmol/L) and a high homocysteine level group(H-tHcy) (≥ 12 µmol/L). Baseline computed tomography (CT) examination was performed. HT was determined via CT or magnetic resonance imaging within 1 to 3 days after admission.

RESULTS

A total of 1858 patients were screened and 1378 patients completed the this study(797 patients in the H-tHcy group and 581 patients in the L-tHcy group). HT incidence was 5.2% (30/581,) in the L-tHcy group and 11.2% (90/797) in the H-tHcy group(P<0.05). Binary logistic regression analysis showed that initial NIHSS score, tHcy levels, treatment with recombinant tissue plasminogen activator thrombolysis, systolic blood pressure on admission, glucose level on admission, smoking status and estimated glomerular filtration rate were independent risk factors for HT. Receiver operating characteristic analysis showed that tHcy level was a moderately sensitive and specific index to predict the incidence of HT, and the optimal cutoff was 16.56 μmol/L (sensitivity 63.3%, specificity 41.3%).

CONCLUSION

Our study findings reveal that high plasma tHcy level is one independent risk factor associated with increased risk of early HT in patients with AIS.

Serum homocysteine level is an independent predictor for hemorrhagic transformation within 24 h of intravenous thrombolysis in acute ischemic stroke

The study aimed to investigate the role of serum homocysteine in hemorrhagic transformation (HT) and symptomatic intracranial hemorrhage (sICH) within 24 h of intravenous (IV) recombinanttissueplasminogenactivator(rt-PA) in acute ischemic stroke (AIS) patients. 236 consecutive AIS patients (169 men, median 65 years old) who underwent to IV rt-PA within 4.5 h of symptom onset were retrospectively recruited and analyzed. The serum homocysteine levels ranged from 4.45 to 67.71 (median 12.05) μmol/L. HT was observed in 28 (11.9%) patients, including 7 (3.0%) sICH patients within 24 h of IV rt-PA. Multiple parameters were compared between HT and non-HT patients as well as sICH and non-sICH patients. The serum homocysteine levels were higher in patients with HT than in those without HT (13.00 vs. 11.70 μmol/L, P = 0.025) and an independent association between serum homocysteine level and HT within 24 h of IV rt-PA was identified via multivariable logistic regression analysis (odds ratio [OR] = 1.103, 95% confidence interval [CI] = 1.021-1.191, P = 0.013). Moreover, serum homocysteine levels were also significantly higher in patients with sICH than in those without sICH (15.19 vs. 11.73 μmol/L, P = 0.005).Our study suggests that serum homocysteine level is an independent predictor for HT within 24 h of IV rt-PA in AIS patients.

Early prediction of the 3-month outcome for individual acute ischemic stroke patients who received intravenous thrombolysis using the N2H3 nomogram model

Background:

The aim of this study was to establish a nomogram model for individualized early prediction of the 3-month prognosis in patients with acute ischemic stroke (AIS) who were treated with intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis.

Methods:

A total of 691 patients were included in this study; 564 patients were included in the training cohort, while 127 patients were included in the test cohort. The main outcome measure was a 3-month unfavorable outcome (modified Rankin Scale 3–6). To construct the nomogram model, stepwise logistic regression analysis was applied to select the significant predictors of the outcome. The discriminative performance of the model was assessed by calculating the area under the receiver operating characteristic curve (AUC-ROC). A decision curve analysis was used to evaluate prognostic value of the model.

Results:

The initial National Institutes of Health Stroke Scale [NIHSS, odds ratio (OR), 1.35; 95% confidence interval (CI), 1.28–1.44; p < 0.001], delta NIHSS (changes in the NIHSS score from baseline to 24 h, OR, 0.75; 95% CI, 0.70–0.79; p < 0.001), hypertension (OR, 2.07; 95% CI, 1.32–3.31; p = 0.002), hyperhomocysteinemia (Hhcy, OR, 2.18; 95% CI, 1.20–4.11; p = 0.013), and the ratio of high-density lipoprotein cholesterol (HDL-C) to low-density lipoprotein cholesterol (LDL-C) (HDL-C/LDL-C, OR, 3.29; 95% CI, 1.00–10.89; p = 0.049) (N2H3) were found to be independent predictors of a 3-month unfavorable outcome from multivariate logistic regression analysis and were incorporated in the N2H3 nomogram model. The AUC-ROC of the training cohort was 0.872 (95% CI, 0.841–0.902), and the AUC-ROC of the test cohort was 0.900 (95% CI, 0.848–0.953).

Conclusion:

The study presented the N2H3 nomogram model, with initial NIHSS score, delta NIHSS, hypertension, Hhcy, and HDL-C/LDL-C as predictors. It therefore provides an individualized early prediction of the 3-month unfavorable outcome in AIS patients treated with intravenous rt-PA thrombolysis.

AST to ALT ratio and risk of hemorrhagic transformation in patients with acute ischemic stroke

BACKGROUND

Hemorrhagic transformation (HT) is a common complication of ischemic stroke. We performed this study to determine whether aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AAR) was related to HT, as well as compare the predictive values of AAR, ALT and AST for HT in patients with ischemic stroke.

METHODS

We included ischemic stroke patients within 7 days of onset. HT was identified by a follow-up imaging examination. Univariate and multivariate logistic regression models were performed to assess the association between AAR and HT. Net reclassification index (NRI) was calculated to assess the ability of AAR, AST and ALT to reclassify risks of HT.

RESULTS

A total of 2042 (median age: 69 years; 63.2% males) patients were included in this study, of whom 232 (11.4%) were identified as HT. The receiver-operating characteristic curve analysis showed that the optimal cut-off value for AAR to predict HT was 1.22. Higher AAR (≥1.22) was an independent predictor associated with HT (OR 1.44, 95%CI 1.06-1.97, P = 0.02) after adjusting for covariates. A U-shaped dose-effect relationship was found between AAR level and HT in logistic regression model with restricted cubic splines. In addition, adding AAR to a model containing conventional risk factors significantly improved predictive power for HT (NRI: 15.4%, P = 0.027), but not for ALT (NRI: 10.3%, P = 0.141) or AST (NRI: 8.3%, P = 0.237).

CONCLUSIONS

Higher AAR was associated with an increased risk of HT after ischemic stroke. In addition, AAR might be a better biomarker for predicting HT than ALT or AST.

Impact of homocysteine levels on clinical outcome in patients with acute ischemic stroke receiving intravenous thrombolysis therapy

Background

The purpose of this study was to retrospectively assess the potential correlation between clinical outcomes and homocysteine (Hcy) levels in acute ischemic stroke (AIS) patients after recombinant tissue plasminogen activator (rtPA) treatment.

Methods

AIS patients treated by rtPA were enrolled between September 2018 and March 2019 in the Stroke Center (Department of Neurology and Neurosurgery), Shanghai Tenth People’s Hospital, Tongji University School of Medicine. Demographics, baseline and clinical characteristics, and modified Rankin Scale (mRS) score after three months from the onset were retrospectively analyzed. Then we compared data about demographics, baseline and clinical characteristics between patients with favorable (mRS score 0–2) and unfavorable (mRS score 3–6) outcomes.

Results

Among 141 patients, 36 patients had poor outcome, for an incidence of 25.53%. Univariate analysis showed that higher Hcy levels (OR = 1.07, 95% CI [1.02–1.12]), older age (OR = 1.06, 95% CI [1.02–1.10]), longer door to needle time (DNT) (OR = 1.03, 95% CI [1.01–1.05]), higher D-Dimer levels (OR = 1.33, 95% CI [1.03–1.71]), and higher National Institutes of Health Stroke Scale (NIHSS) score before treatment (OR = 1.21, 95% CI [1.08–1.35]) were each associated with poor outcome. Also, without internal carotid artery plaque (OR = 0.30, 95% CI [0.10–0.92]) showed a protective effect on patients’ clinical outcome. Patients with higher levels of Hcy decline also showed an increased risk of poor outcome for AIS patients obtaining rtPA treatment (Non-adjusted: OR = 1.07, 95% CI [1.02–1.12]; Adjust model I adjusts for demographics (age, male): OR = 1.06, 95% CI [1.02–1.11]; Adjust model II adjusts for hospital care factors (onset to treatment, DNT): OR = 1.08, 95% CI [1.03–1.13]; Adjust model III adjusts for health and stroke factors (INR, D-Dimer, HGB, NIHSS score before treatment, smoking, drinking, hypertension, diabetes, coronary disease, hyperlipidemia, previous stroke, atrial fibrillation, hemorrhagic transformation, internal carotid artery plaque): OR = 1.06, 95% CI [1.02–1.11]). The results are very stable in all three models constructed.

Conclusion

The results of this study indicate that increased Hcy level independently predicts unfavorable outcome in AIS patients accepting thrombolytic therapy. However, the contribution of Hcy to the outcome, although significant, is relatively small and perhaps not clinically significant when all the other confounders are considered.