Outcomes after acute ischemic stroke in patients with thrombocytopenia or thrombocytosis

Machine learning-based scoring model for predicting mortality in ICU-admitted ischemic stroke patients with moderate to severe consciousness disorders

Background

Stroke is a leading cause of mortality and disability globally. Among ischemic stroke patients, those with moderate to severe consciousness disorders constitute a particularly high-risk subgroup. Accurate predictive models are essential for guiding clinical decisions in this population. This study aimed to develop and validate an automated scoring system using machine learning algorithms for predicting short-term (3- and 7-day) and relatively long-term (30- and 90-day) mortality in this population.

Methods

This retrospective observational study utilized data from the MIMIC-IV database, including 648 ischemic stroke patients with Glasgow Coma Scale (GCS) scores ≤12, admitted to the ICU between 2008 and 2019. Patients with GCS scores indicating speech dysfunction but clear consciousness were excluded. A total of 47 candidate variables were evaluated, and the top six predictors for each mortality model were identified using the AutoScore framework. Model performance was assessed using the area under the curve (AUC) from receiver operating characteristic (ROC) analyses.

Results

The median age of the cohort was 76.8 years (IQR, 64.97-86.34), with mortality rates of 8.02% at 3 days, 18.67% at 7 days, 33.49% at 30 days, and 38.89% at 90 days. The AUCs for the test cohort's 3-, 7-, 30-, and 90-day mortality prediction models were 0.698, 0.678, 0.724, and 0.730, respectively.

Conclusion

We developed and validated a novel machine learning-based scoring tool that effectively predicts both short-term and relatively long-term mortality in ischemic stroke patients with moderate to severe consciousness disorders. This tool has the potential to enhance clinical decision-making and resource allocation for these patients in the ICU.

Antiphospholipid Antibodies Modify the Prognostic Value of Baseline Platelet Count for Clinical Outcomes After Ischemic Stroke

BACKGROUND

Antiphospholipid antibodies (aPLs) have been reported to be involved in platelet-mediated thrombosis and inflammation, but the impact on the prognosis of ischemic stroke remains unclear. We aimed to examine whether the association between baseline platelet count (PLT) and long-term clinical outcomes within 2 years after ischemic stroke onset is modulated by aPLs.

METHODS AND RESULTS

A total of 2938 patients with ischemic stroke were included in this prospective cohort study. Cox proportional hazards regression models were used to assess the association between the baseline PLT stratified by aPLs status and 2-year clinical outcomes after stroke onset, and an interaction effect between PLT and aPLs on clinical outcomes was tested by likelihood ratio test. There was a significant interaction effect of aPLs and PLT on recurrent stroke (Pinteraction=0.002) and cardiovascular events (Pinteraction=0.001) within 2 years after stroke onset. After multivariate adjustment, high PLT was associated with increased risks of recurrent stroke (hazard ratio [HR], 2.78 [95% CI, 1.03-7.45]; Ptrend=0.039) and cardiovascular events (HR, 2.58 [95% CI, 1.12-5.90]; Ptrend=0.024) when 2 extreme tertiles were compared among patients with aPL positive, but not among those with aPL negative.

CONCLUSIONS

The aPLs had a modifying effect on the association between PLT and clinical outcomes within 2 years after ischemic stroke onset. Increased PLT was associated with recurrent stroke and cardiovascular events after ischemic stroke onset among patients with aPL positive, but not in those with aPL negative.

Thrombocytopenia and In-hospital outcomes in patients with acute ischemic stroke undergoing intravenous thrombolysis: Findings from a nationwide registry study in China

BACKGROUND AND OBJECTIVE

Our study aimed to evaluate the associations between platelet count (PC) and in-hospital outcomes for patients with stroke after rt-PA intravenous thrombolysis.

METHODS

We identified patients who had been hospitalized with a primary diagnosis of stroke and had received rt-PA intravenous thrombolysis from June 2015 to July 2019 at participating hospitals in the Chinese Stroke Center Alliance. PC measured before intravenous thrombolysis was categorized into the following four groups: severe thrombocytopenia (PC < 100 × 109/L), mild thrombocytopenia (100 ≤ PC < 150 × 109/L), normal PC (150 ≤ PC ≤ 450 × 109/L), and thrombocythemia (PC > 450 × 109/L). Outcomes were determined from clinical data collected during hospitalization. The primary clinical outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes were mortality, bleeding events, gastrointestinal (GI) hemorrhage, and in-hospital stroke recurrence. We used multivariate logistic regression models to evaluate the associations between PC and outcomes.

RESULTS

We included 44,882 individuals with a median age of 66 years, of whom 34.7 % were female, 951 (2.1 %) had severe thrombocytopenia, 7218 (16.1 %) had mild thrombocytopenia, 36,522 (81.4 %) had a normal PC, and 191 (0.4 %) had thrombocythemia. Both severe and mild thrombocytopenia groups had higher risks of bleeding events (adjusted OR 1.30; 95 % CI,1.01-1.67; p = 0.045; adjusted OR 1.32; 95 % CI,1.19-1.46; p < 0.001) and sICH (adjusted OR 1.48;95 % CI,1.13-1.94; p = 0.005; adjusted OR 1.43;95 % CI,1.27-1.60; p < 0.001) than the normal PC group. Patients with 100 ≤ PC < 150 × 109/L also had a higher risk of in-hospital stroke recurrence (adjusted OR 1.12; 95 % CI,1.02-1.22; p = 0.02).

CONCLUSIONS

Intravenous thrombolysis brings a high risk of sICH given PC < 150 × 109/L, especially PC < 100 × 109/L. It indicated that PC < 100 × 109/L is a reasonable contraindication to thrombolysis.

Safety of Mechanical Thrombectomy for Acute Ischemic Stroke in Patients with Thrombocytopenia

BACKGROUND AND AIM

The impact of low platelet count on outcomes in patients with Acute Ischemic Stroke (AIS) undergoing Mechanical Thrombectomy (MT) is still unclear. In this study we have further explored the effect of thrombocytopenia on the safety and efficacy of MT in patients with anterior circulation Large Vessel Occlusion (LVO) stroke.

MATERIALS AND METHODS

Patients with AIS who underwent MT at our center between June 2015 and November 2021 were examined. Based on the platelet count recorded on admission patients were divided into two groups: those with thrombocytopenia (<150 × 109/L) and those without thrombocytopenia (≥ 150 × 109/L). Symptomatic Intracranial Hemorrhage (sICH) was the primary safety outcome. The efficacy outcome was functional independence defined as a 90-day modified Rankin Scale (mRS) score of 0-2. Multivariate logistic regression models were used to determine the risk factors for post-procedure sICH and 90-day functional outcomes.

RESULTS

Among 302 patients included in the study, thrombocytopenia was detected in 111 (36.8%) cases. Univariate analysis showed age, the proportion of atrial fibrillation, the rates of sICH, 90-day poor outcomes, and mortality to be higher in patients with thrombocytopenia (all p <0.05). Multivariable analysis showed thrombocytopenia to be independently associated with a higher rate of sICH (OR 2.022, 95% CI 1.074-3.807, p =0.029) however, thrombocytopenia did not affect the 90-day functional outcomes (OR 1.045, 95%CI 0.490-2.230, p =0.909) and mortality (OR 1.389, 95% CI 0.467- 4.130 p = 0.554).

CONCLUSION

Thrombocytopenia may increase the risk of sICH but not affect the 90-day functional outcomes and mortality in patients with AIS treated with MT.

The association between long-term platelet count and disability-free survival among middle-aged and older Chinese: Evidence from the China Health and Retirement Longitudinal Study

BACKGROUND AND AIMS

We aimed to assess the associations of baseline and long-term platelet count (PLT) with disability-free survival (DFS) among middle-aged and older Chinese.

METHODS AND RESULTS

A total of 7296 participants were recruited in the analysis. Updated mean PLT was defined as the mean of the two PLT measurements (4 years between wave 1-3). The long-term status of PLT was defined as persistent low, attenuated, increased and persistent high PLT according to the optimal cut points from the receiver operating characteristic curves of the two PLT measurements, respectively. The primary outcome was DFS, evaluated by the first occurrence of either disability or mortality. During 6-year visit, 1579 participants experienced disability or all-cause mortality. The rates of primary outcome were significantly higher among participants with elevated baseline PLT and updated mean PLT. Multivariable adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of primary outcome were 1.253 (1.049-1.496) for highest baseline PLT tertile and 1.532 (1.124-2.088) for highest updated mean PLT tertile, comparing to the lowest tertiles. Multivariable-adjusted spline regression models showed a linear association of baseline PLT (p_linearity < 0.001) and updated mean PLT (p_linearity = 0.005) with primary outcome. Moreover, participants with persistent high PLT and increased PLT had increased risk of primary outcome (ORs [95% CIs]: 1.825 [1.282-2.597] and 1.767 [1.046-2.985], respectively), compared with the reference of those with persistent low PLT.

CONCLUSION

This study proved elevated baseline PLT, especially long-term persist high or increased PLT was associated with less likelihood of DFS among middle-aged and older Chinese.

Is Thrombocytopenia an In-Hospital Mortality Risk Factor among Patients with Acute Ischemic Stroke? A Propensity Score-Matched Analysis from the MIMIC-IV Database

(1) Background: We aimed to evaluate the aspect of thrombocytopenia in patients with acute ischemic stroke (AIS); (2) Methods: Patients with AIS were recruited in the Medical Information Mart for Intensive Care IV database from 2008 to 2019. The thrombocytopenia was defined as a platelet blood count of less than 150 K/µL. We compared the patient characteristics and clinical outcomes using propensity score matching (PSM); (3) Results: Thrombocytopenia affected 151 out of the 1236 patients (12.2%). Patients with thrombocytopenia were older (70.5 ± 12.8 vs. 68.4 ± 14.4; SMD = 0.154) and had a higher Charlson comorbidity index (7.3 ± 2.5 vs. 6.7 ± 2.7; SMD = 0.228) and acute physiology score III (44.8 ± 21.0 vs. 38.2 ± 19.1; SMD = 0.328) than those without thrombocytopenia. The risk of in-hospital mortality did not increase linearly or nonlinearly with a lower platelet count (overall p value = 0.794; nonlinear p value = 0.646). After PSM, 147 pairs remained. Thrombocytopenia was not linked with in-hospital mortality (HR: 1.06, 95% CIs: 0.60-1.88); (4) Conclusions: We described the clinical characteristics of patients admitted for thrombocytopenia and AIS who did not receive reperfusion therapy; additionally, we found that thrombocytopenia was not an independent short-term risk factor of in-hospital mortality.

Influence of Thrombocytopenia on the Outcome of Mechanical Thrombectomy in Patients with Acute Ischemic Stroke

OBJECTIVES

Mechanical thrombectomy (MT) has become leading treatment option for acute ischemic stroke (AIS) due to large vessels occlusion (LVO). Platelet counts may affect outcome in patients with AIS or transient ischemic attack. The aim of our study was to determine the influence of thrombocytopenia on the safety and efficacy of MT in patients with AIS due to anterior circulation LVO.

MATERIALS AND METHODS

This study included 127 consecutive adult patients with AIS due to anterior circulation LVO who underwent MT. The patients were divided into 2 groups based on initial platelet count: with thrombocytopenia (<150 × 10⁹/L) and without thrombocytopenia (≥150 × 10⁹/L). Primary safety outcome was symptomatic intracerebral haemorrhage (SICH), while secondary safety outcome was stroke-related mortality. Efficacy outcome was functional independence, defined as modified Rankin Scale (mRS) score 0-2. Follow- up time was 90 days.

RESULTS

Initial thrombocytopenia (<150 × 10⁹/L) was detected in 19 (15%) patients. Multivariable analysis showed that initial thrombocytopenia did not increase the risk of SICH and did not affect the short-term functional outcome (p = 0.587). However, initial thrombocytopenia increased the risk for stroke-related mortality (aOR 3.639, 95% CI 1.079-12.641, p = 0.037). The main cause of mortality in the group with thrombocytopenia was malignant cerebral infarction (44.4%).

CONCLUSIONS

Thrombocytopenia does not affect the efficacy and the risk of SICH in patients with AIS caused by anterior circulation LVO treated with MT. However, the risk of mortality is higher in patients with thrombocytopenia, mainly due to malignant cerebral infarction.

Long-Term Safety and Efficacy of Antiplatelet Therapy in Patients With Cerebral Infarction With Thrombocytopenia

This study aimed to investigate the long-term safety and benefits of antiplatelet therapy in patients with cerebral infarction with thrombocytopenia, as evidence regarding this was limited. This cohort trial assessed patients with acute cerebral infarction with thrombocytopenia treated in the Neurology Department of Shanghai Tenth People's Hospital from January 2016 to December 2018, and enrolled patients were followed up for 9 months. The patients were divided into non-antiplatelet and antiplatelet groups based on the actual intake of antiplatelet drugs. Primary endpoints included hemorrhagic events, recurrence of cerebral infarction, and activity of daily living (ADL) score changes. To balance baseline clinical data, propensity score matching was applied, and there were finally 65 matched patients, including 30 and 35 in the antiplatelet and non-antiplatelet groups, respectively. There were no differences in hemorrhagic and cerebral infarction recurrence rates between the 2 groups. ADL score change was higher in the antiplatelet group than in the non-antiplatelet group (10 vs 5, p = 0.039). In multivariate regression analysis, antiplatelet therapy significantly predicted a positive change in ADL scores [B = 8.381, 95% confidence interval (0.56-16.19)]. In patients with acute cerebral infarction with thrombocytopenia, antiplatelet therapy could the improve the quality of life in the chronic stage.

Ischemic stroke/transient ischemic attack in adults with primary immune thrombocytopenia: a meta-analysis

OBJECTIVE

To carry out a systematic review to help resolve the controversy of ischemic stroke (IS)/transient ischemic attack (TIA) in patients with primary immune thrombocytopenia (ITP).

METHODS

A database search of PubMed and Ovid Embase was conducted for epidemiologic studies published up to December 17, 2019. The effective size was estimated by pooled prevalence, annualized incidence/risk, relative risk (RR), and their corresponding 95% confidence intervals (CIs).

RESULTS

The systematic review included 14 eligible studies from 11 publications. The pooled annualized cumulative incidence was 0.15% (95% CI, 0.03-0.26%) per person-years. And the pooled annualized cumulative risk of IS/TIA of ITP was 0.86% (95% CI, 0.33-1.39%) per year based on 3 population-based cohort studies. There was a higher risk of incident IS/TIA in ITP patients than ITP-free subjects (pooled unadjusted or adjusted RR with 95% CI, 1.46 [1.22-1.74] or 1.50 [1.29-1.73]).

CONCLUSIONS

IS/TIA was not uncommon in patients with primary ITP. ITP patients have a higher risk of IS/TIA compared with the reference cohorts. Healthcare professionals should take into account the risk of IS/TIA when treating ITP patients with or without a history of IS/TIA.

Influence of lipoprotein-associated phospholipase A2 mass on prognosis value of baseline platelet count for clinical outcomes after acute ischemic stroke

BACKGROUND AND AIMS

We aimed to examine the association between baseline platelet count (PLT) and prognosis of acute ischemic stroke according to lipoprotein-associated phospholipase A₂ (Lp-PLA₂) mass.

METHODS

A total of 3254 patients with acute ischemic stroke were included in this analysis. The primary outcome was a combination of major disability and all-cause mortality (modified Rankin Scale score ≥3) at 3 months after stroke. Secondary outcome was major disability and all-cause mortality, respectively.

RESULTS

The prognosis value of PLT for primary outcome was significantly modified by Lp-PLA₂ mass (p_interaction = 0.002). After multivariate adjustment, elevated PLT was associated with the increased risk of primary outcome in patients with high Lp-PLA₂ mass (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.09-2.48; p_trend = 0.002), but not in those with low Lp-PLA₂ mass (OR, 0.94; 95%CI, 0.62-1.42; p_trend = 0.181), when comparing two extreme PLT quartiles. A similar association was found between elevated PLT and major disability (p_interaction = 0.001). Elevated PLT was associated with increased risk of major disability only in patients with high Lp-PLA₂ mass (OR, 1.54; 95%CI, 1.03-2.31; p_trend = 0.007), for the highest quartile vs the lowest quartile. Each 100 × 10⁹/L increment in PLT was associated with 42% (95%CI, 12%-79%) increased risk of primary outcome and 33% (95%CI, 6%-68%) increased risk of major disability in those with high Lp-PLA₂ mass.

CONCLUSIONS

The elevated PLT was associated with poor prognosis of acute ischemic stroke only in patients with high Lp-PLA₂ mass. Lp-PLA₂ might be an important factor influencing the prognosis value of PLT for clinical outcomes in acute ischemic stroke patients.

Thrombocytopenia and platelet course on hospital mortality in neurological intensive care unit: a retrospective observational study from large database

BACKGROUND

Thrombocytopenia (TP) has been shown to be an independent predictor of mortality in the intensive care unit (ICU) patients. Studies are lacking in the neurological ICU (NICU) population. The aim was to evaluate the incidence of TP in NICU and the relationship between TP and outcomes.

METHODS

We conducted a retrospective multicenter study of prospectively collected data of all patients admitted to the NICU between 2014 and 2015 from a large database (eICU Collaborative Research Database). The main exposure was TP at admission and TP developed during NICU stay. Multivariable logistic regression and Cox proportional hazard models were used to evaluate the relationship of TP at admission and platelet course with hospital mortality. The primary outcome was hospital mortality.

RESULTS

7450 patients in NICU from 17 hospitals were included. Hospital mortality was 9%. TP at admission was present in 20% of patients, TP developed during NICU stay was present in 13.2% of patients. TP at admission was not associated with hospital mortality after adjusting for confounders (OR 1.14 [95% CI 0.92-1.41, p = 0.237]). Hospital mortality of continuous TP during NICU stay was 15% while hospital mortality of recovery from TP at admission was 6% (p < 0.001). Patients with TP developed during NICU stay had higher odds ratio for hospital mortality (OR 1.65 [95% CI 1.3-2.09, p < 0.001]).

CONCLUSIONS

Thrombocytopenia is common in NICU and patients who have thrombocytopenia not resolving have increased mortality. Patients' recovery from thrombocytopenia may predict a good prognosis.

The Contrasting Role of Extracellular Vesicles in Vascular Inflammation and Tissue Repair

Extracellular vesicles are a heterogeneous family of vesicles, generated from different subcellular compartments and released into the extracellular space. Composed of a lipid bilayer encompassing both soluble cytosolic material and nuclear components, these organelles have been recently described as novel regulators of intercellular communication between adjacent and remote cells. Due to their diversified composition and biological content, they portray specific signatures of cellular activation and pathological processes, their potential as diagnostic and prognostic biomarkers has raised significant interest in cardiovascular diseases. Circulating vesicles, especially those released from platelets, leukocytes, and endothelial cells are found to play a critical role in activating several fundamental cells within the vasculature, including endothelial cells and vascular smooth muscle cells. Their intrinsic activity and immunomodulatory properties lends them to not only promote vascular inflammation, but also enhance tissue regeneration, vascular repair, and indeed resolution. In this review we aim to recapitulate the recent findings concerning the roles played by EVs that originate from different circulating cells, with particular reference to their action on the endothelium. We focus herein, on the interaction of platelet and leukocyte EVs with the endothelium. In addition, their potential biological function in promoting tissue resolution and vascular repair will also be discussed.

Clinical Variables and Genetic Risk Factors Associated with the Acute Outcome of Ischemic Stroke: A Systematic Review

Stroke is a complex disease and one of the main causes of morbidity and mortality among the adult population. A huge variety of factors is known to influence patient outcome, including demographic variables, comorbidities or genetics. In this review, we expound what is known about the influence of clinical variables and related genetic risk factors on ischemic stroke outcome, focusing on acute and subacute outcome (within 24 to 48 hours after stroke and until day 10, respectively), as they are the first indicators of stroke damage. We searched the PubMed data base for articles that investigated the interaction between clinical variables or genetic factors and acute or subacute stroke outcome. A total of 61 studies were finally included in this review. Regarding the data collected, the variables consistently associated with acute stroke outcome are: glucose levels, blood pressure, presence of atrial fibrillation, prior statin treatment, stroke severity, type of acute treatment performed, severe neurological complications, leukocyte levels, and genetic risk factors. Further research and international efforts are required in this field, which should include genome-wide association studies.

Platelet Count Predicts Adverse Clinical Outcomes After Ischemic Stroke or TIA: Subgroup Analysis of CNSR II

Background: The clinical significance of platelet count (PC) for ischemic cerebrovascular disease is not well-established and further risk stratification according to baseline PC within normal range has not been reported before. We aim to evaluate the prognostic effect of baseline circulating PC within normal range on the risk of long-term recurrent stroke, mortality and functional outcomes after ischemic stroke or TIA.

Methods: We derived data from eligible patients with ischemic stroke or TIA from the China National Stroke Registry (CNSR) II. Participants were divided into quintiles according to baseline PC within normal range (100–450 × 10⁹/L). Multivariable cox regression and logistic regression were adopted to explore the correlation of baseline PC with recurrent stroke, mortality and poor functional outcomes (modified Rankin Scale 3~6) within 1-year follow-up.

Results: Among the16842 eligible participants, the average age was 64.7 ± 11.9, 1,241 (7.4%) had recurrent stroke, 1,377 (8.2%) died, and 3,557 (21.1%) ended up with poor functional outcomes after 1-year follow-up. Compared with the third PC quintile (186–212 × 10⁹/L), patients in the top quintile (249–450 × 10⁹/L) presented with increased risk of recurrent stroke (adjusted hazard ratio 1.21, [1.02–1.45]), all-cause mortality (adjusted hazard ratio 1.43, [1.19–1.73]), and poor functional outcome (adjusted odds ratio 1.49, [1.28–1.74]), while patients in the lowest PC quintile(100–155 × 10⁹/L) had higher risk of poor functional outcome (adjusted odds ratio 1.19, [1.02–1.38]).

Conclusion: In ischemic stroke or TIA patients with platelet count within normal range, platelet count may be a qualified predictor for long-term recurrent stroke, mortality, and poor functional outcome.

Thrombocytopenia and declines in platelet counts: predictors of mortality and outcome after mechanical thrombectomy

BACKGROUND AND PURPOSE

Acute ischemic stroke (AIS) has well-known risk factors. The role of platelets in patients treated using mechanical thrombectomy (MT) has not been studied. The aim of this study was to study if there is an association of initial thrombocytopenia (TP) and a decline of platelets counts (DPC) with the clinical outcomes, mortality and intracranial hemorrhage (ICH) rates in AIS patients treated with MT.

MATERIALS AND METHODS

In a case-control study consecutive MT-stroke patients were analyzed. A multivariate logistic regression model was used to test for good clinical outcome (mRS 90 days <= 2) and mortality adjusting for age, initial NIHSS, pretreatment with tPA, statins and platelet inhibitors, occlusion site, time from symptom onset to recanalization, initial TP (< 150 × 10⁹/L) and DPC (> 26%). Additionally, rates of ICH were compared.

RESULTS

Of 294 patients included, 9.6% had an initial TP and 23.8% a DPC > 26%. The mortality rate in patients with normal platelet counts was 26.1% vs. 48.3% (p = 0.002) in patients with initial TP with an aOR of 3.47 (CI 1.28-9.4, p = 0.005). No difference regarding the rate of good clinical outcome (p = 0.204) and ICH (p = 0.18) was observed. A DPC of more than 26% during the first 5 days of hospitalization predicted the rate of mortality (aOR 2.4 CI 1.14-5.04, p = 0.021) and the chances of a good clinical outcome (aOR 0.291 CI 0.128-0.666, p = 0.003) without significant differences of ICH rates (p = 0.735).

CONCLUSION

In AIS patients treated with MT an initial TP was independently associated with higher mortality rates and a marked DPC with higher mortality rates as well as poorer clinical outcomes.

Platelet count is associated with outcome in cancer patients with stroke

INTRODUCTION

Cerebrovascular disease (CVD) and cancer are among the most common causes of mortality worldwide, preceded only by ischemic heart disease (IHD). Thrombocytopenia was shown to be associated with poor outcomes in IHD and CVD in the general population. This study aimed to assess the relationship of thrombocytopenia with poor outcomes in cancer patients with CVD.

MATERIALS AND METHODS

Data on patients with concomitant CVD and cancer who were initially treated at a cancer referral center between January 2010 and December 2017 were included. Thrombocytopenia was defined as a platelet count < 150,000/mm³ during the first 24 h of CVD symptom onset. The IRB (CI/837/17) approved the review of clinical records.

RESULTS

Among 268 cancer patients with CVD included in the study, 210 met the inclusion criteria. Median overall survival of the entire cohort was 7.2 months, which was significantly shorter in males (p = 0.029) and patients with hematologic tumors (p = 0.009), hemorrhagic CVD (p < 0.001), altered mental status (p < 0.001), and thrombocytopenia (p < 0.001). Multiple regression logistic analysis revealed that thrombocytopenia (risk ratio [RR] 1.6, 95% confidence interval [CI] 1.1-2.4) and altered mental status (RR 2.7, 95% CI 1.9-4.0) remained statistically significant risk factors for mortality.

CONCLUSION

In cancer patients with CVD, thrombocytopenia at the time of CVD diagnosis and altered mental status during initial clinical evaluation were associated with higher mortality, which should be confirmed in future studies.

Intravenous thrombolysis and platelet count

OBJECTIVE

To study the effect of platelet count (PC) on bleeding risk and outcome in stroke patients treated with IV thrombolysis (IVT) and to explore whether withholding IVT in PC < 100 × 10⁹/L is supported.

METHODS

In this prospective multicenter, IVT register-based study, we compared PC with symptomatic intracranial hemorrhage (sICH; Second European-Australasian Acute Stroke Study [ECASS II] criteria), poor outcome (modified Rankin Scale score 3-6), and mortality at 3 months. PC was used as a continuous and categorical variable distinguishing thrombocytopenia (<150 × 10⁹/L), thrombocytosis (>450 × 10⁹/L), and normal PC (150-450 × 10⁹/L [reference group]). Moreover, PC < 100 × 10⁹/L was compared to PC ≥ 100 × 10⁹/L. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) from the logistic regression models were calculated.

RESULTS

Among 7,533 IVT-treated stroke patients, 6,830 (90.7%) had normal PC, 595 (7.9%) had thrombocytopenia, and 108 (1.4%) had thrombocytosis. Decreasing PC (every 10 × 10⁹/L) was associated with increasing risk of sICH (OR_adjusted 1.03, 95% CI 1.02-1.05) but decreasing risk of poor outcome (OR_adjusted 0.99, 95% CI 0.98-0.99) and mortality (OR_adjusted 0.98, 95% CI 0.98-0.99). The risk of sICH was higher in patients with thrombocytopenic than in patients with normal PC (OR_adjusted 1.73, 95% CI 1.24-2.43). However, the risk of poor outcome (OR_adjusted 0.89, 95% CI 0.39-1.97) and mortality (OR_adjusted 1.09, 95% CI 0.83-1.44) did not differ significantly. Thrombocytosis was associated with mortality (OR_adjusted 2.02, 95% CI 1.21-3.37). Forty-four (0.3%) patients had PC < 100 × 10⁹/L. Their risks of sICH (OR_unadjusted 1.56, 95% CI 0.48-5.07), poor outcome (OR_adjusted 1.63, 95% CI 0.82-3.24), and mortality (OR_adjusted 1.38, 95% CI 0.64-2.98) did not differ significantly from those of patients with PC ≥ 100 × 10⁹/L.

CONCLUSION

Lower PC was associated with increased risk of sICH, while higher PC indicated increased mortality. Our data suggest that PC modifies outcome and complications in individual patients, while withholding IVT in all patients with PC < 100 × 10⁹/L is challenged.

De Ritis ratio (AST/ALT) as an independent predictor of poor outcome in patients with acute ischemic stroke

PURPOSE

The aspartate transaminase/alanine transaminase ratio (De Ritis ratio, AAR) was reported to be associated with patients' prognosis in certain diseases recently. The objective of the current study was to determine the association between the AAR at admission and poor outcome at 3 months in acute ischemic stroke (AIS) patients.

PATIENTS AND METHODS

This retrospective cohort study included patients who experienced their first-ever AIS between June 2015 and March 2016. The primary outcome measure was a poor outcome at 3 months (modified Rankin Scale score >2). Multivariate logistic regression models were used to assess the relationship between AAR quartiles and clinical outcomes among the AIS patients. Receiver operating characteristic curve analysis was applied to identify the optimal cutoff for AAR in predicting the prognosis of AIS.

RESULTS

In terms of the relationship between poor outcome and AAR, the adjusted odds ratio comparing the highest and lowest AAR quartiles was 2.15 (95% confidence interval =1.14-4.05). An AAR of 1.53 was identified as the optimal cutoff. In a prespecified subgroup analysis according to the time from symptom onset to treatment (>24 vs ≤24 hours), there was no significant difference in the effect of AAR >1.53 between the two groups.

CONCLUSION

An increased AAR at admission is significantly associated with a poor outcome at 3 months in AIS patients.

Effect of Hypokalemia on Functional Outcome at 3 Months Post-Stroke Among First-Ever Acute Ischemic Stroke Patients

Background

Hypokalemia has been confirmed to be a predictor of adverse cardiovascular and renal outcomes. There is a paucity of studies focusing on the potential connection between the serum K⁺ level and the outcome after acute ischemic stroke (AIS). This study investigated whether hypokalemia in the acute stroke stage contributes to worse functional outcome in AIS patients.

Material/Methods

This retrospective cohort study included consecutive patients with first-ever AIS admitted between June 2015 and March 2016. Patients were divided into 2 groups: hypokalemia (K⁺ <3.5 mmol/L) and normokalemia (3.5 mmol/L ≤K⁺ ≤5.5 mmol/L). Primary outcome measure was poor outcome at 3 months (modified Rankin scale >2). Univariate and multivariate logistic regression analyses were used to assess the association between hypokalemia and poor outcome. Receiver operating curve (ROC) analysis was performed to determine the optimal cutoff point of serum K⁺ level for predicting poor outcome.

Results

The percent of patients with poor outcome at 3 months was higher in the hypokalemic group (62.9%) than in the normokalemic group (45.5%). Hypokalemic patients tended to have lower fasting glucose at admission, lower Glasgow coma scale score, and longer time from symptom onset to treatment compared with normokalemic patients. Hypokalemia was associated with poor outcome at 3 months after adjusting for potential confounders (odds ratio=2.42, 95% confidence interval=1.21–4.86, P=0.013). ROC analysis showed that the optimal threshold for serum K⁺ level was 3.7 mmol/L.

Conclusions

Hypokalemia at the initial admission is associated with poor prognosis at 3 months in first-ever AIS patients.

Platelets Proteomic Profiles of Acute Ischemic Stroke Patients

Platelets play a crucial role in the pathogenesis of stroke and antiplatelet agents exist for its treatment and prevention. Through the use of LC-MS based protein expression profiling, platelets from stroke patients were analyzed and then correlated with the proteomic analyses results in the context of this disease. This study was based on patients who post ischemic stroke were admitted to hospital and had venous blood drawn within 24 hrs of the incidence. Label-free protein expression analyses of the platelets' tryptic digest was performed in triplicate on a UPLC-ESI-qTOF-MS/MS system and ProteinLynx Global Server (v2.5, Waters) was used for tandem mass data extraction. The peptide sequences were searched against the reviewed homo sapiens database (www.uniprot.org) and the quantitation of protein variation was achieved through Progenesis LC-MS software (V4.0, Nonlinear Dynamics). These Label-free differential proteomics analysis of platelets ensured that 500 proteins were identified and 83 of these proteins were found to be statistically significant. The differentially expressed proteins are involved in various processes such as inflammatory response, cellular movement, immune cell trafficking, cell-to-cell signaling and interaction, hematological system development and function and nucleic acid metabolism. The expressions of myeloperoxidase, arachidonate 12-Lipoxygenase and histidine-rich glycoprotein are involved in cellular metabolic processes, crk-like protein and ras homolog gene family member A involved in cell signaling with vitronectin, thrombospondin 1, Integrin alpha 2b, and integrin beta 3 involved in cell adhesion. Apolipoprotein H, immunoglobulin heavy constant gamma 1 and immunoglobulin heavy constant gamma 3 are involved in structural, apolipoprotein A-I, and alpha-1-microglobulin/bikunin precursor is involved in transport, complement component 3 and clusterin is involved in immunity proteins as has been discussed. Our data provides an insight into the proteins that are involved in the platelets' activation response during ischemic stroke. It could be argued that this study lays the foundation for future mechanistic studies.