Association of Serum Calcium Levels with Infarct Size in Acute Ischemic Stroke: Observations from Northeast India

Clinical features and associated factors of coexisting intracerebral hemorrhage in patients with cerebral small vessel disease: a cross-sectional study

Intracerebral hemorrhage (ICH) is generally considered to be closely related to cerebral small vessel disease (CSVD), leading to a poor prognosis. However, the coexistence of ICH in general CSVD patients and related factors remain underreported. In our cross-sectional study, we screened 414 CSVD patients from a database at the Department of Neurology, First Affiliated Hospital of Zhengzhou University (September 2018 to April 2022). Imaging biomarkers of CSVD and coexisting ICH lesion were assessed. Factors associated with coexisting ICH in CSVD were determined using multivariate logistic regression analysis. ICH was observed in 59 patients (14.3%). Multivariate logistic regression showed that previous history of ischemic stroke or transient ischemic attack (OR 5.189, 95%CI 2.572-10.467, P < 0.001), high-grade perivascular space in the basal ganglia (n > 10) (OR 2.051, 95%CI 1.044-4.027, P = 0.037) and low adjusted calcium-phosphorus product (OR 0.728 per 1 [mmol/L]2 increase, 95%CI 0.531-0.998, P = 0.049) were associated with coexisting ICH in CSVD patients. The considerable proportion of coexisting ICH and revelation of associated factors in general CSVD patients alert physicians of the potential risk of the reoccurrence of ICH, and might have a significant impact on therapeutic strategies.

Effects of Prolonged Serum Calcium Suppression during Extracorporeal Cardiopulmonary Resuscitation in Pigs

Controlled reperfusion by monitoring the blood pressure, blood flow, and specific blood parameters during extracorporeal reperfusion after cardiac arrest has the potential to limit ischemia-reperfusion injury. The intracellular calcium overload as part of the ischemia-reperfusion injury provides the possibility for the injury to be counteracted by the early suppression of serum calcium with the aim of improving survival and the neurological outcome. We investigated the effects of prolonged serum calcium suppression via sodium citrate during extracorporeal resuscitation using the CARL protocol (CARL-controlled automated reperfusion of the whole body) compared to a single-dose approach in a porcine model after prolonged cardiac arrest. A control group (N = 10) was resuscitated after a 20 min cardiac arrest, initially lowering the intravascular calcium with the help of a single dose of sodium citrate as part of the priming solution. Animals in the intervention group (N = 13) received additional sodium citrate for the first 15 min of reperfusion. In the control group, 9/10 (90.0%) animals survived until day 7 and 7/13 (53.8%) survived in the intervention group (p = 0.09). A favorable neurological outcome on day 7 after the cardiac arrest was observed in all the surviving animals using a species-specific neurological deficit score. The coronary perfusion pressure was significantly lower with a tendency towards more cardiac arrhythmias in the intervention group. In conclusion, a prolonged reduction in serum calcium levels over the first 15 min of reperfusion after prolonged cardiac arrest tended to be unfavorable regarding survival and hemodynamic variables compared to a single-dose approach in this animal model.

Association of Serum Calcium With Infarct Size and Severity in Acute Ischemic Stroke: A Rural Hospital-Based Cross-Sectional Study

Background One of the major mediators of ischemic neuronal cell death is calcium. It has been found that elevated serum calcium is associated with a better prognosis in patients with ischemic stroke. This study highlights the association of serum calcium, albumin-corrected calcium, and ionic calcium with the size of acute ischemic stroke as well as severity outcome in terms of the National Institutes of Health Stroke Scale (NIHSS) score and Barthel Index. Methods This cross-sectional study was conducted on 85 cases of acute ischemic stroke (based on a computerized tomography scan of the brain) from September 2019 to October 2021. All included patients had undergone complete clinical history, systemic examination, as well as estimation of serum total calcium, albumin corrected calcium, and ionic calcium. NIHSS score and Barthel Index were used to access the severity of each subject.  Results A significant positive correlation was seen between infarct size with NIHSS with a correlation coefficient of 0.35. A significant negative correlation was seen between infarct size with serum calcium, albumin-corrected calcium, and Barthel Index with a correlation coefficient of -0.483, -0.354, and -0.365 respectively. No correlation was seen between infarct size and ionic calcium with a correlation coefficient of 0.082. Conclusion It can be concluded that higher normal levels of serum calcium and albumin-corrected calcium are associated with a smaller-sized infarct and had less severity index among patients with acute ischemic stroke.

Association of serum calcium levels with clinical severity of ischemic stroke at the time of admission as defined by NIHSS score: A cross-sectional, observational study

Introduction

Calcium plays an important role in the pathogenesis of ischemic cell damage. Intracellular calcium accumulation leads to neuronal damage by triggering the cycle of cytotoxic events. In this study, the association of serum calcium levels with clinical severity of ischemic stroke as defined by the National Institute of Health Stroke Scale (NIHSS) score was evaluated.

Materials and Methods

After obtaining ethical approval from the institutional ethics committee, data was collected from 60 ischemic stroke patients, who were divided into two groups of 30 patients each: group 1 with serum ionized calcium less than 4.5 mg/dl and group 2 with serum ionized calcium levels more than 4.5 mg/dl. The stroke severity in the two groups was assessed using the NIHSS score.

Results

The severity of ischemic stroke according to the NIHSS score was greater in patients with low serum ionized calcium levels compared to the severity of ischemic stroke in patients with normal serum ionized calcium levels.

Conclusion

Serum ionized calcium certainly plays a role in the pathogenesis of ischemic stroke by influencing the cycle of cytotoxic events that result in ischemic cell death. This study showed that the severity of ischemic stroke was greater in patients with low serum ionized calcium levels compared to patients with normal serum ionized calcium levels.

Phosphodiesterase-5 Inhibitor Attenuates Anxious Phenotypes and Movement Disorder Induced by Mild Ischemic Stroke in Rats

Objective

Patients with mild ischemic stroke experience various sequela and residual symptoms, such as anxious behavior and deficits in movement. Few approaches have been proved to be effective and safe therapeutic approaches for patients with mild ischemic stroke by acute stroke. Sildenafil (SIL), a phosphodiesterase-5 inhibitor (PDE5i), is a known remedy for neurodegenerative disorders and vascular dementia through its angiogenesis and neurogenesis effects. In this study, we investigated the efficacy of PDE5i in the emotional and behavioral abnormalities in rats with mild ischemic stroke.

Methods

We divided the rats into four groups as follows (n=20, respectively) : group 1, naïve; group 2, middle cerebral artery occlusion (MCAo30); group 3, MCAo30+SIL-pre; and group 4, MCAo30+SIL-post. In the case of drug administration groups, single dose of PDE5i (sildenafil citrate, 20 mg/kg) was given at 30-minute before and after reperfusion of MCAo in rats. After surgery, we investigated and confirmed the therapeutic effect of sildenafil on histology, immunofluorescence, behavioral assays and neural oscillations.

Results

Sildenafil alleviated a neuronal loss and reduced the infarction volume. And results of behavior task and immunofluorescence shown possibility that anti-inflammation process and improve motor deficits sildenafil treatment after mild ischemic stroke. Furthermore, sildenafil treatment attenuated the alteration of theta-frequency rhythm in the CA1 region of the hippocampus, a known neural oscillatory marker for anxiety disorder in rodents, induced by mild ischemic stroke.

Conclusion

PDE5i as effective therapeutic agents for anxiety and movement disorders and provide robust preclinical evidence to support the development and use of PDE5i for the treatment of mild ischemic stroke residual disorders.

Association of serum calcium levels with infarct volume and stroke scores in acute ischemic stroke patients: An observational study

BACKGROUND

Stroke vastly contributes to death and disability worldwide. Acute ischemic stroke (AIS) is caused by a reduction in supply of blood to the brain. Accumulation of unnecessary intracellular serum calcium in AIS induces the cytotoxic actions that activates enzymes involved in cell death. The present investigation assessed the relationship of total serum calcium level (at admission) and initial diffusion weighted imaging (DWI) infarct volume and correlated with National Institute of Health Stroke Scale (NIHSS) scores.

METHODS

A hospital-based observational study was conducted on 74 consecutive patients identified with AIS fulfilling the inclusion criteria. NIHSS scores and serum ionized calcium were calculated in every patient and compared with DWI infarct volume for assessing correlation between these three. Statistical software R Version 4.0.2 and Microsoft Excel were used for statistical analysis.

RESULTS

Out of the 74 patients, most of them were in age group of 50-69 years, with a male preponderance (68.9%). A significant association was noticed between diabetes and dyslipidemia with age (P=0.01499). A strong negative correlation was observed between NIHSS scores (at admission & discharge) with ionized calcium, while a strong positive correlation was noticed between stroke scores with infarct volume. A statistically significant negative correlation was recorded between serum calcium (on admission) and infarct size (r=-0.851755, P=0.0001). The mean of NIHSS scores on admission (8.24±5.19) has been remarkably higher when compared with NIHSS scores at discharge (5.25±3.89).

CONCLUSION

In patients with AIS examined within 6-24 hours of symptoms onset, serum ionized calcium and volume of infarct on DWI showed inverse association. Serum calcium serves as a marker of severity and acts as prognostic factor in AIS.

Role of Calcium Homeostasis in Ischemic Stroke: A Review

:

Stroke is the second most common cause of death worldwide. It occurs due to the insufficient supply of oxygen-rich blood to the brain. It is a complex disease with multiple associated risk factors including smoking, alcoholism, age, sex, ethnicity, etc. Calcium ions are known to play a vital role in cell death pathways, which is a ubiquitous intracellular messenger during and immediately after an ischemic period. Disruption in normal calcium hemostasis is known to be a major initiator and activator of the ischemic cell death pathway. Under Ischemic stroke conditions, glutamate is released from the neurons and glia which further activates the N-methyl-D-aspartate (NMDA) receptor and triggers the rapid translocation of Ca2+ from extracellular to intracellular spaces in cerebral tissues and vice versa. Various studies indicated that Ca2+ could have harmful effects on neurons under acute ischemic conditions. Mitochondrial dysfunction also contributes to delayed neuronal death, and it was established decades ago that massive calcium accumulation triggers mitochondrial damage. Elevated Ca2+ levels cause mitochondria to swell and release their contents. As a result oxidative stress and mitochondrial calcium accumulation activate mitochondrial permeability transition and lead to depolarization-coupled production of reactive oxygen species. This association between calcium levels and mitochondrial death suggests that elevated calcium levels might have a role in the neurological outcome in ischemic stroke. Previous studies have also reported that elevated Ca2+ levels play a role in the determination of infarct size, outcome, and recurrence of ischemic stroke. The current review has been compiled to understand the multidimensional role of altered Ca2+ levels in the initiation and alteration of neuronal death after ischemic attack. The underlying mechanisms understood to date have also been discussed.

In situ metabolite and lipid analysis of GluN2D-/- and wild-type mice after ischemic stroke using MALDI MSI

The N-methyl-D-aspartate (NMDA) receptor is a crucial mediator of pathological glutamate-driven excitotoxicity and subsequent neuronal death in acute ischemic stroke. Although the roles of the NMDAR's composite GluN2A-C subunits have been investigated in this phenomenon, the relative importance of the GluN2D subunit has yet to be evaluated. Herein, GluN2D^-/- mice were studied in a model of ischemic stroke using MALDI FT-ICR mass spectrometry imaging to investigate the role of the GluN2D subunit of the NMDA receptor in brain ischemia. GluN2D^-/- mice underwent middle cerebral artery occlusion (MCAO) and brain tissue was subsequently harvested, frozen, and cryosectioned. Tissue sections were analyzed via MALDI FT-ICR mass spectrometry imaging. MALDI analyses revealed increases in several calcium-related species, namely vitamin D metabolites, LysoPC, and several PS species, in wild-type mouse brain tissue when compared to wild type. In addition, GluN2D^-/- mice also displayed an increase in PC, as well as a decrease in DG, suggesting reduced free fatty acid release from brain ischemia. These trends indicate that GluN2D^-/- mice show enhanced rates of neurorecovery and neuroprotection from ischemic strokes compared to wild-type mice. The cause of neuroprotection may be the result of an increase in PGP in knockout mice, contributing to greater cardiolipin synthesis and decreased sensitivity to apoptotic signals. Graphical abstract.

Admission Serum Calcium Level as a Prognostic Marker for Intracerebral Hemorrhage

BACKGROUND

Prognostic significance of serum calcium level in patients with intracerebral hemorrhage is not well studied. The aim of the study was to identify if a relationship between admission serum calcium level and prognosis exists in patients with intracerebral hemorrhage.

METHODS

A total of 1262 confirmed intracerebral hemorrhage patients were included. Demographic data, medical history, medicine history, laboratory data, imaging data, clinical score, and progress note were collected from their medical records. All images of head computed tomography were reanalyzed. Ninety-day prognosis was recorded, and poor outcome was defined as death or major disability caused by intracerebral hemorrhage.

RESULTS

During the 90-day follow-up period, 504 patients died and 226 patients suffered from major disability. Death and major disability were combined as poor prognosis. The remaining 532 patients showed good prognosis. Admission serum calcium level was lower in the patients with poor prognosis than in the patients with good prognosis (2.41 ± 0.23 mmol/l, 2.55 ± 0.26 mmol/l, P < 0.001). Admission INR and hematoma volume were higher in the patients with poor prognosis than in the patients with good prognosis (INR: 1.74 ± 0.29, 1.70 ± 0.29, P = 0.029; hematoma volume: 11.6 ± 4.4 ml, 10.7 ± 4.1 ml, P < 0.001). There was no difference in admission APTT level between the two prognosis groups (28.4 ± 5.6 s, 27.8 ± 5.4 s, P = 0.056). A multivariate COX regression analysis reported that admission serum calcium level ≤ 2.41 mmol/l was associated with the increased risk of poor prognosis (death or major disability) in the patients (HR 1.45, 95% CI 1.32-1.60). In addition, there was a significant linear association of serum calcium level with coagulation function markers and hematoma volume on admission (APTT: r = - 0.091, P = 0.001; INR: r = - 0.063, P = 0.025; hematoma volume: r = -0.108, P < 0.001).

CONCLUSIONS

Admission serum calcium level might be a prognostic marker for intracerebral hemorrhage. Potential mechanism involved calcium-induced coagulation function abnormality.