Dynamic Changes in Fibrinogen and Prognosis of Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Stroke severity influences correlation of fibrinogen with early neurological deterioration after thrombolytic therapy

BACKGROUND

To investigate the relationships between fibrinogen levels at baseline and 24 hours after intravenous thrombolysis (IVT) and early neurological deterioration (END); and to investigate whether stroke severity influences the correlation between fibrinogen and END.

METHODS

The fibrinogen levels were measured at admission and 24 hours after intravenous thrombolysis (IVT) in 364 consecutive AIS patients. Regression analysis, stratified analyses and interaction tests were utilized to assess the relationship between fibrinogen and END and whether stroke severity (NIHSS<6 vs NIHSS≥6) influences the correlation.

RESULTS

Fibrinogen at admission was not independently associated with END after adjusting for potential confounders (OR, 1.00; 95 % CI, 0.66-1.53; P = 0.9874). However, increased fibrinogen levels after IVT were associated with increased risk of END (OR, 1.49; 95 % CI, 1.00-2.21; P = 0.0479). Fibrinogen after IVT was not independently associated with END (OR, 1.12; 95 % CI, 0.26-4.80; P = 0.8737) in patients with NIHSS<6, but was independently associated with END in patients with NIHSS≥6 (OR, 1.90; 95 % CI, 1.15-3.15; P = 0.0120). And the interaction test for NIHSS (NIHSS<6 vs NIHSS≥6) was statistically significant (P = 0.0366). Similar results were still found when we used the median NIHSS score of our study population (<10 vs ≥10) as a stratification criterion (Pinteraction = 0.0487).

CONCLUSIONS

Fibrinogen after IVT but not on admission was independently associated with END. And stroke severity influenced the correlation between fibrinogen after IVT and END.

Development and validation of a prognostic nomogram for predicting poor outcomes following intravenous rt-PA in patients with acute ischemic stroke

Background

Intravenous administration of recombinant tissue plasminogen activator (rt-PA) within 4.5 h of symptom onset is a standard treatment for acute ischemic stroke (AIS). However, certain patients continue to develop unfavorable outcomes despite timely rt-PA therapy. Identifying those at high risk is essential for developing individualized care plans and establishing appropriate follow-up.

Methods

This retrospective study included AIS patients treated with intravenous rt-PA at 0.9 mg/kg at our center. Outcomes at three months were evaluated using the modified Rankin Scale (mRS). Patients with mRS scores ≤2 were considered to have favorable outcomes, and those with scores >2 were considered to have poor outcomes. Univariable analysis and stepwise logistic regression were used to identify independent predictors of poor prognosis, and a nomogram was subsequently developed. The model's discriminative power was assessed with area under the receiver operating characteristic curves (AUC-ROC), and its calibration was examined using calibration plots. Decision curves and clinical impact curves were applied to determine clinical utility.

Results

Among 392 enrolled patients, 77 had poor outcomes three months after rt-PA therapy. Fibrinogen (Fg), baseline NIHSS, and a history of hypertension emerged as independent predictors of poor prognosis. The nomogram achieved an AUC of 0.948 (95% CI [0.910-0.985]), with sensitivity of 0.900 and specificity of 0.916 in the training dataset, and an AUC of 0.959 (95% CI [0.907-1.000]), with sensitivity of 0.943 and specificity of 0.947 in the validation dataset. Calibration plots demonstrated close agreement between predicted and observed probabilities, and decision curves indicated a wide range of net benefit threshold probabilities.

Conclusions

This nomogram, incorporating baseline NIHSS, Fg, and a history of hypertension, accurately predicts poor three-month outcomes in AIS patients treated with intravenous rt-PA. Its ease of use may facilitate early risk stratification and assist clinicians in formulating more targeted management strategies and follow-up protocols for patients likely to experience unfavorable outcomes.

The Role of Fibrinogen in Mediating NGAL-Associated Neuronal Damage in Acute Ischemic Stroke: A Moderated Mediation Analysis

Background

Both neutrophil gelatinase-associated lipocalin (NGAL) and fibrinogen are involved in the inflammation in acute ischemic stroke (AIS), but the interaction among them is unknown. Clarifying this issue will contribute to a better understanding of the mechanisms of injury in AIS. This study aimed to explore the association between NGAL, fibrinogen and neuronal damage in AIS.

Methods

This study is a cross-section study. One hundred ninety-six successively hospitalized AIS patients in Renji Hospital in China between January 1, 2023, and May 31, 2023, were included. Circulating NGAL and fibrinogen were measured, and neuron-specific enolase (NSE) was detected to evaluate central neuronal damage. All data were analyzed by linear curve fitting analysis, multiple linear regression analysis, and moderated mediation analysis, respectively.

Results

There are linear relationships between log2-transformed NGAL, NSE, and fibrinogen, respectively. The β (95%) for the positive association between log2-transformed NGAL and NSE was 2.24 (1.15-3.32, p < 0.01), between log2-transformed NGAL and fibrinogen was 0.37 (0.19-0.56, p < 0.01), and between fibrinogen and NSE was 1.16 (0.48-1.85, p < 0.01) adjusting for potential confounders. These associations remained consistent in sensitivity analysis and hierarchical analysis. Increased fibrinogen significantly (p < 0.01) mediated 14.28% of log2-transformed NGAL-associated increased NSE risk.

Conclusion

The NGAL levels were associated with NSE, and the NGAL-associated neuronal damage might be partially mediated by fibrinogen, suggesting that the inflammatory response among NGAL, fibrinogen, and NSE should be intervened to reduce neuronal damage after ischemic stroke. Further animal experiments are needed to clarify their specific mechanisms and precise relationships.

The Change in Fibrinogen is Associated with Outcome in Patients with Acute Ischemic Stroke Treated with Endovascular Thrombectomy

BACKGROUND

Fibrinogen has been identified as a modulator of the coagulation and inflammatory process. There is uncertainty about the relationship between the dynamic profile of fibrinogen levels and its impact on clinical outcomes in patients with acute ischemic stroke treated with endovascular thrombectomy.

METHODS

We consecutively enrolled patients with acute ischemic stroke who underwent endovascular thrombectomy. Fibrinogen was measured on admission and during hospitalization. The change in fibrinogen (Δfibrinogen) was calculated as the highest follow-up fibrinogen minus admission fibrinogen, with a positive Δfibrinogen indicating an increase in fibrinogen level. Functional outcome was assessed by the modified Rankin Scale at 3 months. Poor outcome was defined as modified Rankin Scale > 2.

RESULTS

A total of 346 patients were included (mean age 67.4 ± 13.6 years, 52.31% men). The median fibrinogen on admission was 2.77 g/L (interquartile range 2.30-3.39 g/L). The median Δfibrinogen was 1.38 g/L (interquartile range 0.27-2.79 g/L). Hyperfibrinogenemia (> 4.5 g/L) on admission was associated with an increased risk of poor outcome [odds ratio (OR) 5.93, 95% confidence interval (CI) 1.44-24.41, p = 0.014]. There was a possible U-shaped association of Δfibrinogen with outcomes, with an inflection point of - 0.43 g/L (p = 0.04). When Δfibrinogen was <  - 0.43 g/L, a higher decrease in fibrinogen (lower Δfibrinogen value) was associated with a higher risk of poor outcome (OR 0.22, 95% CI 0.02-2.48, p = 0.219). When Δfibrinogen was >  - 0.43 g/L, the risk of poor outcome increased with increasing fibrinogen (OR 1.27, 95% CI 1.04-1.54, p = 0.016).

CONCLUSIONS

In patients with endovascular thrombectomy, hyperfibrinogenemia on admission was associated with poor functional outcomes at 3 months, whereas Δfibrinogen was associated with poor 3-month outcomes in a possible U-shaped manner.

Predictive value of fibrinogen levels for 90-day functional outcomes after intravenous thrombolysis in patients with acute ischaemic stroke

PURPOSE

We aimed to investigate the correlation between fibrinogen levels and functional outcomes at 90 days after intravenous thrombolysis therapy (IVT) in patients with acute ischaemic stroke (AIS).

METHODS

We identified patients with AIS who received IVT (alteplase 0.6 or 0.9 mg/kg) between 1 January 2019 and 31 March 2022 in Yancheng 1st People's Hospital. Fibrinogen levels were measured before IVT, and the 90-day post-stroke functional outcome was evaluated using the modified Rankin Scale (mRS). An mRS score of 0-2 indicated functional independence, whereas an mRS score of 3-6 indicated functional dependence. Potential outcome predictors were evaluated using univariate and multivariate analyses, and receiver operating characteristic (ROC) curve analysis was performed to assess the performance of fibrinogen levels in predicting the 90-day outcome.

RESULTS

A total of 276 patients with AIS who received IVT within 4.5 h of stroke onset were enrolled, of whom 165 and 111 were categorised into the functional independence and functional dependence groups, respectively. Univariate analysis showed that the fibrinogen, homocysteine, high-density lipoprotein cholesterol, and D-dimer levels; age; National Institutes of Health Stroke Scale (NIHSS) score on admission; NIHSS score 24 h after IVT; and incidence of cardioembolism were higher in the functional dependence group than in the functional independence group (P < 0.05). Meanwhile, the thrombin time and the incidence of small-vessel occlusion in the functional dependence group were smaller than those in the functional independence group (P < 0.05). Multivariate logistic regression analysis showed that fibrinogen and homocysteine levels were both independent risk factors for 90-day functional dependence in patients with AIS (odds ratio [OR] 2.822, 95% confidence interval [95% CI]: 1.214-6.558, P = 0.016 for fibrinogen; OR 1.048, 95 %CI: 1.002-1.096, P = 0.041 for homocysteine). The area under the ROC curve of fibrinogen levels before IVT for predicting poor functional outcomes was 0.664, with a sensitivity, specificity, positive predictive value, and negative predictive value of 40.9%, 80.8%, 68.9%, and 64.3%, respectively.

CONCLUSION

In patients with AIS, fibrinogen levels have a certain predictive value for short-term functional outcomes after IVT.

Circulating Leukocyte as an Inflammatory Biomarker: Association with Fibrinogen and Neuronal Damage in Acute Ischemic Stroke

Background and Purpose

Leukocytes and fibrinogen are inflammatory markers involved in circulating and central inflammatory response after ischemic stroke. However, the interaction between circulating leukocytes and serum fibrinogen and neuronal injury in acute ischemic stroke (AIS) patients is still unclear. The present study aimed to investigate the association between circulating leukocyte and serum fibrinogen and neuronal injury respectively in AIS.

Methods

A cross-section study with 431 hospitalized AIS patients from department of neurology was performed. Circulating leukocytes and fibrinogen were measured, and neuron-specific enolase (NSE) was detected to evaluate central neuronal damage. A propensity score matching method was used to minimize the effects of confounding factors. The relationship between leukocytes and NSE and fibrinogen was analyzed by linear curve fitting analysis and multiple logistic regression models respectively.

Results

The mean levels of NSE, leukocyte, and fibrinogen were significantly higher in the matched AIS group (n=89) than those of in the healthy control group (n=89) (all p<0.05). Both serum NSE and fibrinogen were increased with the increasing of leukocyte in AIS patients (both p<0.05). Smoothed plots suggested that there are linear relationships between leukocyte and NSE and fibrinogen respectively. Multiple logistic regression analysis showed the OR (95%) for the relationship between leukocyte and high NSE were 1.13 (1.01-1.26, p=0.031) and 1.13 (1.00-1.28, p=0.048), and between leukocyte and high fibrinogen were 1.40 (1.22-1.61, p<0.001) and 1.35 (1.15-1.58, p<0.001) in all AIS patients before and after adjusting for potential confounders.

Conclusion

Our study suggests that elevated circulating leukocyte was associated with high fibrinogen and neuronal injury in AIS. Therefore, there may be potential targets among circulating leukocyte, fibrinogen and NSE that should be intervened to reduce inflammatory reaction after ischemic stroke.

Acute Ischemic Stroke Comorbid with Type 2 Diabetes: Long-Term Prognosis Determinants in a 36-Month Prospective Study for Personalized Medicine

Ischemic stroke (IS) is often comorbid with type 2 diabetes mellitus (T2DM) wherein the determinants of long-term outcomes, beyond the acute stroke phase, are not adequately known. This study identified the determinants of long-term outcomes for diabetic IS patients through a prospective nested case-control study in 624 patients treated with conservative measures (38.60% females, mean age: 63.85 years). After 36-month follow-up, 117 (18.8%) patients with poor outcome were enrolled in the case group. The poor outcome was defined with a modified Rankin Scale (mRS) score ≥3. Meanwhile, 374 (59.9%) patients with good outcome, defined as (mRS score <3), were included in the control group. Patients who died (n = 32) or lost to follow-up (n = 101) were excluded in analysis. Poor prognostic outcome was positively associated with (1) the pulse rate at admission, (2) diastolic blood pressure (DBP), and (3) fasting blood glucose (FBG) during follow-up, whereas physical activity and lipid-lowering treatment during follow-up were negatively associated. Importantly, a forecasting model with these indicators distinguished the patients with good versus poor outcomes with 70.1% sensitivity and 73.5% specificity. Health care professionals and laboratory medicine scholars may want to monitor an increase in DBP and FBG during follow-up, as well as physical activity and lipid-lowering treatment, in relationship to the prognosis of IS with comorbid T2DM after conservative therapies. The proposed predictive model for personalized/precision medicine requires field testing in independent studies, and might help risk stratification with theranostic tests for patients with acute IS who also have a diagnosis of T2DM.

Elevated Albumin to Globulin Ratio on Day 7 is Associated with Improved Function Outcomes in Acute Ischemic Stroke Patients with Intravenous Thrombolysis

Background and Purpose

Albumin to globulin ratio (A/G) has been established as a representative biomarker for assessing inflammation and nutritional status. However, the prognostic value of A/G has rarely been reported in acute ischemic stroke (AIS) patients with intravenous thrombolysis (IVT).

Methods

A total of 311 AIS patients who had undergone IVT and completed 3-month follow-up were retrospectively recruited in this study. Albumin (Alb), globulin (Glb) and A/G on admission, within 24 hours after IVT and on day 7 were recorded. Poor outcome was defined as death or major disability (modified Rankin Scale, 3–6) at 3 months.

Results

Among the 311 cases, 260 patients had admission blood samples, 296 cases had blood samples within 24 hours after IVT and 126 cases had blood samples on day 7. The patients with and without available blood samples were well-balanced. During the first 24 h, we observed A/G to increase significantly compared with baseline whereas at day 7 it was almost back to baseline in patients with a poor outcome. Receiver operating characteristic (ROC) curves analysis showed that A/G had a better performance in discriminating patients at high risk and low risk of a poor outcome than either Alb or Glb alone and carried the highest predictive ability on day 7 (AUC = 0.807). Lower 7-day A/G was independently associated with a poor outcome (per-SD increase, OR = 0.182, 95% CI: 0.074–0.446).

Conclusion

A/G is an important prognostic indicator for AIS outcomes and merits dynamic monitoring.

The Relationship Between the Fibrinogen to Albumin Ratio and Early Outcomes in Patients with Acute Pontine Infarction

Previous studies have indicated that fibrinogen and low serum albumin levels are associated with poor outcomes of acute ischemic stroke. The role of the fibrinogen-to-albumin ratio (FAR) as a novel inflammatory and thrombotic biomarker in acute ischemic stroke is unclear. This study aims to investigate the relationship between the FAR and 3-month outcomes of acute pontine infarction. Methods: Patients with acute pontine infarction were consecutively included. All patients were followed up at 3 months after onset, and the 3-month outcome was evaluated using modified Rankin Scale (mRS) scores. A score of 0 to 2 was defined as a good outcome, and a score ≥ 3 was defined as a poor outcome. Receiver operating curve (ROC) analysis was used to calculate the optimal cutoff values for patients with acute pontine infarction. Then, a binary logistic regression model was used to evaluate the risk factors for a poor outcome after acute pontine infarction. Results: A total of 264 patients with acute pontine infarction were included. Eighty (30.3%) patients were included in the poor outcome group. The optimal cutoff value of the FAR for predicting the 3-month outcome of acute pontine infarction was 8.199. The FAR was independently associated with a poor outcome at 3 months in patients with acute pontine infarction (odds ratio [OR] = 1.293, 95% confidence interval [CI]: 1.150-1.453). Conclusions: We found that a high FAR predicted poor 3-month outcomes in patients with acute pontine infarction.

Clinical Significance and Dynamic Change of Coagulation Parameters in Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Objective

Investigations on coagulation parameters including fibrinogen (Fbg), fibrinogen degradation products (FDP), and D-dimer in ischemic stroke patients treated with intravenous thrombolysis are insufficient. We aimed to investigate the association between in-hospital clinical outcomes and the coagulation parameters at different time points in ischemic stroke patients treated with intravenous tissues plasminogen activator (IV tPA).

Methods

We retrospectively enrolled patients who received IV tPA therapy within 4.5 h from symptoms onset. Demographics, clinical characteristics, imaging measures, and the discharge mRS score were collected. Multivariable logistic regression analyses were performed to test whether coagulation parameters were independent predictors for the in-hospital clinical outcomes. We also employed machine learning models to investigate whether coagulation parameters were able to improve the prediction of favorable functional outcomes.

Results

One hundred and fifty-two patients treated with IV tPA were included. Among the coagulation parameters, low D-dimers at 48 h proved to be an independent predictor of favorable functional outcome (adjusted odd ratio 0.24, 95% confidential intervals 0.06-0.92, P  =  0.04). The AUC of D-dimer at 48 h to predict favorable functional outcome was 0.73 (0.60-0.87) and the optimal cut-off value was 0.92 (sensitivity 0.69, specificity 0.78). Machine learning models with D-dimer at 48 h had superior performance in predicting favorable functional outcomes and among the input variables in the machine learning models, D-dimer at 48 h showed the highest weight in predicting mRS 0-1 at discharge (38.44%).

Conclusion

Increased levels of D-dimer at 48 h was associated with lower proportion of favorable functional outcomes in acute ischemic stroke patients with intravenous thrombolysis.

Predictive value of D-dimer/albumin ratio and fibrinogen/albumin ratio for in-hospital mortality in patients with COVID-19

INTRODUCTION

Due to the high mortality of coronavirus disease 2019 (COVID-19), there are difficulties in the managing emergency department. We investigated whether the D-dimer/albumin ratio (DAR) and fibrinogen/albumin ratio (FAR) predict mortality in the COVID-19 patients.

METHODS

A total of 717 COVID-19 patients who were brought to the emergency department from March to October 2020 were included in the study. Levels of D-dimer, fibrinogen and albumin, as well as DAR, FAR, age, gender and in-hospital mortality status of the patients, were recorded. The patients were grouped by in-hospital mortality. Statistical comparison was conducted between the groups.

RESULTS

Of the patients included in the study, 371 (51.7%) were male, and their median age was 64 years (50-74). There was in-hospital mortality in 126 (17.6%) patients. The area under the curve (AUC) and odds ratio values obtained by DAR to predict in-hospital mortality were higher than the values obtained by the all other parameters (AUC of DAR, albumin, D-dimer, FAR and fibrinogen: 0.773, 0.766, 0.757, 0.703 and 0.637, respectively; odds ratio of DAR > 56.36, albumin < 4.015, D-dimer > 292.5, FAR > 112.33 and fibrinogen > 423:7.898, 6.216, 6.058, 4.437 and 2.794, respectively). In addition; patients with concurrent DAR > 56.36 and FAR > 112.33 had an odds ratio of 21.879 with respect to patients with concurrent DAR < 56.36 and FAR < 112.33.

CONCLUSION

DAR may be used as a new marker to predict mortality in COVID-19 patients. In addition, the concurrent high DARs and FARs were found to be more valuable in predicting in-hospital mortality than either separately.