Serum magnesium but not calcium was associated with hemorrhagic transformation in stroke overall and stroke subtypes: a case-control study in China

Administration of Calcium and Magnesium in Acute Intracerebral Hemorrhage Patients: Assessing Safety and Feasibility

BACKGROUND

Serum calcium and magnesium levels are a key factor of the coagulation cascade and may potentially contribute to the pathophysiology of intracerebral hemorrhage (ICH) expansion. The aim of this study was to attain and sustain target levels of serum calcium and magnesium for three days following admission.

METHODS

A single-blind, prospective, multicenter randomized study was conducted from 2019 to 2022 years, enrolling acute ICH patients aged 18-80 years, with radiological diagnosis and without surgical intervention. Participants were randomly assigned in a 1:1 ratio to either the study group or the control group. In the study group, the target serum levels of calcium (9-10.2 mg/dL) and magnesium (2-3 mg/dL) were actively achieved and maintained for a duration of 3 days following admission. The primary outcome was the expansion of ICH volume within the first 3 days between the study group and the control groups.

RESULTS

After implementing inclusion/exclusion criteria, 105 of 354 patients remained in the study. There were no significant differences in ICH volume on hospital days 2 and 3 between the groups. Admission factors including Glasgow coma scale score, hemoglobin level, ICH volume, and spot sign showed significant correlations in multivariate analysis. On the third day of hospitalization, admission serum magnesium levels showed a significant correlation with ICH expansion, whereas calcium levels did not.

CONCLUSION

Admission serum magnesium levels were found to correlate with hematoma expansion in patients with acute ICH. While magnesium itself may not be a direct therapeutic target, it could serve as a valuable indicator for identifying potential therapeutic strategies aimed at preventing ICH volume increase.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0004427.

Hypomagnesemia is Associated with the Skull Computed Tomography Black Hole Sign in Patients with Spontaneous Intracerebral Hemorrhage

OBJECTIVES

The evaluation of hypomagnesemia's significance in predicting the presence of the black hole sign in patients with intracranial hemorrhage is currently under investigation.

METHODS

The study included 261 patients with cerebral hemorrhage who underwent initial skull computed tomography within 24 hours of admission. Sixty-nine patients (26.4%) exhibited hypomagnesemia in the initial laboratory examinations. The black hole sign was observed in 123 patients (referred to as the black hole sign group, which includes patients with and without hypomagnesemia), while the remaining 138 patients (nonblack hole sign group) did not exhibit this feature. The values of hypomagnesemia were assessed through multivariable logistic regression analyses.

RESULTS

The black hole sign occurred in 45 of the 69 (65.2%) patients with hypomagnesemia, and in 78 of the 192 (40.6%) patients without hypomagnesemia. In the black hole sign group, hypomagnesemia was observed in 45 patients (36.6%). However, only 24 patients (19.5%) from the normal magnesium concentration group exhibited hypomagnesemia. The sensitivity, specificity, and positive and negative predictive values of hypomagnesemia for predicting the black hole sign were 69.9%, 82.5%, 36.6%, and 82.8%, respectively. The odds ratios for hypomagnesemia, smoking history, and hypokalemia in predicting the presence of the black hole sign were 2.74, 1.971, and 1.629, correspondingly.

CONCLUSIONS

The presence of hypomagnesemia may serve as a predictive factor for the black hole sign and rebleeding in patients with intracerebral hemorrhage, thereby providing valuable guidance for clinical treatment.

Abnormal serum Magnesium Level is Associated with the Coagulopathy in Traumatic Brain Injury Patients

BACKGROUND

Coagulopathy is associated with poor prognosis of traumatic brain injury (TBI) patients. This study is performed to explore the association between serum magnesium level and the risk of coagulopathy in TBI.

METHODS

TBI patients from the Medical Information Mart for Intensive Care-III database were included for this study. Logistic regression analysis was performed to explore risk factors and develop a predictive model for coagulopathy in TBI. The restricted cubic spline (RCS) was utilized to analyze the association between serum magnesium level and the development of coagulopathy. Receiver operating characteristic curve was drawn to evaluate the performance of the predictive model for coagulopathy.

RESULTS

The incidence of coagulopathy in TBI was 32.6%. The RCS indicated the association between magnesium and coagulopathy was U-shaped. Multivariate logistic regression confirmed age, coronary heart disease, cerebral vascular disease, chronic liver disease, GCS, ISS, epidural hematoma, hemoglobin, shock index and magnesium level were independently associated with the coagulopathy in TBI. Compared with patients of magnesium level between 1.7 and 2.3 mg/dL, those with magnesium level below 1.7 mg/dL or above 2.2 mg/dL had a higher risk of coagulopathy.

CONCLUSION

Both hypermagnesemia and hypomagnesemia are associated with higher risk of coagulopathy in TBI patients. Physicians should pay more attention on preventing coagulopathy in TBI patients with hypomagnesemia or hypermagnesemia.

Predictive Factors for Hemorrhagic Transformation in Acute Ischemic Stroke in the REAL-World Clinical Practice

BACKGROUND

Few data exists on predictive factors of hemorrhagic transformation (HT) in real-world acute ischemic stroke patients. The aims of this study were: (i) to identify predictive variables of HT (ii) to develop a score for predicting HT.

METHODS

We retrospectively analyzed the clinical, radiographic, and laboratory data of patients with acute ischemic stroke consecutively admitted to our Stroke Unit along two years. Patients with HT were compared with those without HT. A multivariate logistic regression analysis was performed to identify independent predictors of HT on CT scan at 24 hours to develop a practical score.

RESULTS

The study population consisted of 564 patients with mean age 77.5±11.8 years. Fifty-two patients (9.2%) showed HT on brain CT at 24 hours (4.9% symptomatic). NIHSS score ≥8 at Stroke Unit admission (3 points), cardioembolic etiology (2 points), acute revascularization by systemic thrombolysis and/or mechanical thrombectomy (1 point), history of previous TIA/stroke (1 point), and major vessel occlusion (1 point) were found independent risk factors of HT and were included in the score (Hemorrhagic Transformation Empoli score (HTE)). The predictive power of HTE score was good with an AUC of 0.785 (95% CI: 0.749-0.818). Compared with 5 HT predictive scores proposed in the literature (THRIVE, SPAN-100, MSS, GRASPS, SITS-SIC), the HTE score significantly better predicted HT.

CONCLUSIONS

NIHSS score ≥8 at Stroke Unit admission, cardioembolism, urgent revascularization, previous TIA/stroke, and major vessel occlusion were independent predictors of HT. The HTE score has a good predictive power for HT. Prospective studies are warranted.

Effect of Magnesium on Deterioration and Symptomatic Hemorrhagic Transformation in Cerebral Ischemia: An Ancillary Analysis of the FAST-MAG Trial

BACKGROUND

Magnesium (Mg) is a neuroprotectant in preclinical models. Lower serum Mg levels have been associated with symptomatic hemorrhagic transformation (HT) in patients with ischemic stroke. Early treatment of acute ischemic stroke with Mg may reduce rates of symptomatic HT.

METHODS

In this post hoc study of the Field Administration of Stroke Therapy Magnesium (FAST-MAG) trial, 1,245 participants with a diagnosis of cerebral ischemia received 20 g of Mg or placebo initiated in the prehospital setting. Posttreatment serum Mg level was measured for 809 participants. Cases of clinical deterioration, defined as worsening by ≥4 points on the National Institute of Health Stroke Scale (NIHSS), were imaged and evaluated for etiology. Symptomatic HT was defined as deterioration with imaging showing new hemorrhage.

RESULTS

Clinical deterioration occurred in 187 and symptomatic HT in 46 of 1,245 cases of cerebral ischemia. Rates of deterioration and symptomatic HT were not significantly lower in those who received Mg (15.7% vs. 14.4%, p = 0.591; 2.8% vs. 4.6%, p = 0.281). In cases where serum Mg level was obtained posttreatment, lower serum Mg level (<1.7 mg/dL) was associated with significantly higher rates of deterioration and symptomatic HT (27.5% vs. 15.5%, p = 0.0261; 11.6% vs. 3.65%, p = 0.00819).

CONCLUSIONS

Treatment with Mg did not significantly reduce rates of clinical deterioration or symptomatic HT. Future analysis should address whether treatment with Mg could have influenced the subgroup with low serum Mg at baseline.

Higher serum albumin-corrected calcium levels are associated with revascularization and poor outcome after mechanical thrombectomy

Background

Serum calcium abnormalities have been determined to be associated with the risk and outcome of stroke. The aim of the present study was to examine the associations of serum calcium with vascular recanalization, symptomatic intracranial haemorrhage and functional outcome in stroke patients after mechanical thrombectomy.

Methods

A total of 192 patients treated with mechanical thrombectomy for anterior circulation large vessel occlusion were consecutively included from August 2017 to June 2021. Serum calcium levels were measured on admission, and albumin-corrected calcium levels were calculated for subsequent analysis. Successful arterial revascularization was defined as a modified Thrombolysis in Cerebral Infarction scale score ≥ 2b. Symptomatic intracranial haemorrhage was assessed according to the European Cooperative Acute Stroke Study (ECASS) III criteria. Poor functional outcome was defined as a modified Rankin Scale score > 2 at 3 months.

Results

Patients with poor outcomes had higher albumin-corrected calcium levels than patients with good outcomes before (2.20 (2.10, 2.30) mmol/L vs. 2.13 (2.04, 2.24) mmol/L, P = 0.002), and after adjusting for other factors (AOR 95% CI, 1.812 (1.253, 2.621), P = 0.002). Patients with unsuccessful recanalization had higher albumin-corrected calcium levels than those with recanalization (2.26 (2.09, 2.46) mmol/L vs. 2.17 (2.07, 2.27) mmol/L, P = 0.029), and after adjusting for other factors (AOR 95% CI, 2.068 (1.214, 3.524)), P = 0.008). No association was found between albumin-corrected calcium and symptomatic intracranial haemorrhage.

Conclusions

Higher serum albumin-corrected calcium levels are independently associated with revascularization and poor outcome in stroke patients after mechanical thrombectomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02856-2.

Association between serum calcium and hemorrhagic transformation in ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Hemorrhagic transformation (HT) is a common complication of ischemic stroke. A growing number of studies have found that serum calcium levels are lower in HT groups than in control groups. However, the relationship between serum calcium and HT remains controversial. We performed a meta-analysis to assess the relationship between serum calcium levels and HT.

METHODS AND RESULTS

Electronic databases were searched for studies on serum calcium and HT from inception to November 6, 2021. Ten studies included in present meta-analysis with a total of 3212 participants. Due to the high heterogeneity (I² = 81%), we chose the random effects model. The results showed that the serum calcium level in the HT group was significantly lower than that in the control group (pooled mean difference, -0.05; 95% confidence interval (CI), (-0.09, -0.02); P = 0.001). Whether thrombolytic or not the results were applied (pooled mean difference, -0.07; 95% CI, (-0.13, -0.01); P = 0.02 and pooled mean difference, -0.03; 95% CI, (-0.06, -0.01); P = 0.007).

CONCLUSIONS

Serum calcium was related to HT and may be one of the risk factors for HT.

Low Serum Magnesium Levels Are Associated With Hemorrhagic Transformation After Mechanical Thrombectomy in Patients With Acute Ischemic Stroke

Objective

In patients with acute ischemic stroke (AIS), hemorrhagic transformation (HT) is a major complication after mechanical thrombectomy (MT). This study aimed to investigate the relationship between serum magnesium levels and HT after MT.

Methods

We collected 199 cases of consecutive AIS that received MT due to acute anterior circulation occlusions in our institution between January 2017 and January 2020. Baseline serum magnesium was obtained from all patients on admission before MT. The patients were divided into two groups based on the occurrence of HT. Univariate and multivariate analyses were performed to investigate whether magnesium was an independent predictor of HT. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were determined.

Results

Of the 199 enrolled patients, 40 (20.1%) presented with HT, and 12 (6%) developed symptomatic intracranial hemorrhage (sICH). Patients with HT had lower serum magnesium levels compared to those without HT (0.76 [0.69–0.80] vs. 0.84 [0.80–0.90], p < 0.001). The multivariate logistic analysis showed that the serum magnesium level (odds ratio, [OR]: 0.000, 95% confidence interval [CI]: 0.000–0.001, p < 0.001) was significantly associated with the occurrence of HT. The ROC curve analysis revealed that the serum magnesium level could predict HT with an AUC of.820 (95% CI: 0.750–0.891 p < 0.001). Serum magnesium ≤ 0.80 mmol/L could predict HT with a sensitivity of 79.2% and a specificity of 70.0%. Of interest, the serum magnesium level was not associated with HT when the baseline of serum magnesium was higher than the cut-off value (0.80 mmol/L) in the subgroup analysis.

Conclusions

Lower baseline serum magnesium levels (<0.80 mmol/L) on admission are associated with increased risk of HT in AIS patients receiving MT.

Low Serum Magnesium Levels Are Associated With Hemorrhagic Transformation After Thrombolysis in Acute Ischemic Stroke

Background: In patients with acute ischemic stroke, hemorrhagic transformation is a major complication after intravenous thrombolysis. This study aimed to investigate the relationship between serum magnesium levels and hemorrhagic transformation (HT) after thrombolytic therapy.

Methods: We retrospectively analyzed data from 242 patients who received thrombolytic therapy at the Second Affiliated Hospital of the Wenzhou Medical University in China. Baseline serum magnesium levels were measured before intravenous thrombolysis, and the occurrence of HT was evaluated using computed tomography images reviewed within 24–36 h after therapy. The relationship between serum magnesium levels and HT was examined using multivariate logistic regression, subgroup analysis, and restricted cubic spline models.

Results: Of the 242 included patients, 43 (17.8%) developed HT. Patients with HT had significant lower serum magnesium levels than those without HT (0.81 ± 0.08 vs. 0.85 ± 0.08 mmol/L, p = 0.007). Multivariable logistic regression analysis indicated that patients with higher serum magnesium levels had lower risk of HT (OR per 0.1-mmol/L increase 0.43, 95% CI 0.27–0.73, p = 0.002). However, this association did not persist when baseline levels of serum magnesium were higher than the median value (0.85 mmol/L) in subgroup analysis (OR per 0.1-mmol/L increase 0.58, 95% CI 0.14–2.51, p = 0.47). This threshold effect was also observed in the restricted cubic spline model when serum magnesium levels were above 0.88 mmol/L. No association between symptomatic HT and serum magnesium levels was observed in our study (OR per 0.1-mmol/L increase 0.52, 95% CI 0.25–1.11, p = 0.092).

Conclusions: Lower serum magnesium levels in patients with ischemic stroke are associated with an increased risk of HT after intravenous thrombolysis, but perhaps only when serum magnesium is below a certain minimal concentration.

Environmental heavy metals and cardiovascular diseases: Status and future direction

Cardiovascular disease (CVD) and environmental degradation are leading global health problems of our time. Recent studies have linked exposure to heavy metals to the risks of CVD and diabetes, particularly in populations from low- and middle-income countries, where concomitant rapid development occurs. In this review, we 1) assessed the totality, quantity, and consistency of the available epidemiological studies, linking heavy metal exposures to the risk of CVD (including stroke and coronary heart disease); 2) discussed the potential biological mechanisms underlying some tantalizing observations in humans; and 3) identified gaps in our knowledge base that must be investigated in future work. An accumulating body of evidence from both experimental and observational studies implicates exposure to heavy metals, in a dose-response manner, in the increased risk of CVD. The limitations of most existing studies include insufficient statistical power, lack of comprehensive assessment of exposure, and cross-sectional design. Given the widespread exposure to heavy metals, an urgent need has emerged to investigate these putative associations of environmental exposures, either independently or jointly, with incident CVD outcomes prospectively in well-characterized cohorts of diverse populations, and to determine potential strategies to prevent and control the impacts of heavy metal exposure on the cardiometabolic health outcomes of individuals and populations.