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Almubayyidh M, Alghamdi I, Parry-Jones AR, Jenkins D. Prehospital identification of intracerebral haemorrhage: a scoping review of early clinical features and portable devices. BMJ Open 2024; 14:e079316. [PMID: 38643005 PMCID: PMC11033659 DOI: 10.1136/bmjopen-2023-079316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 03/26/2024] [Indexed: 04/22/2024] Open
Abstract
INTRODUCTION Prehospital identification of intracerebral haemorrhage (ICH) in suspected stroke cases may enable the initiation of appropriate treatments and facilitate better-informed transport decisions. This scoping review aims to examine the literature to identify early clinical features and portable devices for the detection of ICH in the prehospital setting. METHODS Three databases were searched via Ovid (MEDLINE, EMBASE and CENTRAL) from inception to August 2022 using prespecified search strategies. One reviewer screened all titles, abstracts and full-text articles for eligibility, while a second reviewer independently screened 20% of the literature during each screening stage. Data extracted were tabulated to summarise the key findings. RESULTS A total of 6803 articles were screened for eligibility, of which 22 studies were included for analysis. Among them, 15 studies reported on early clinical features, while 7 considered portable devices. Associations between age, sex and comorbidities with the presence of ICH varied across studies. However, most studies reported that patients with ICH exhibited more severe neurological deficits (n=6) and higher blood pressure levels (n=11) at onset compared with other stroke and non-stroke diagnoses. Four technologies were identified for ICH detection: microwave imaging technology, volumetric impedance phase shift spectroscopy, transcranial ultrasound and electroencephalography. Microwave and ultrasound imaging techniques showed promise in distinguishing ICH from other diagnoses. CONCLUSION This scoping review has identified potential clinical features for the identification of ICH in suspected stroke patients. However, the considerable heterogeneity among the included studies precludes meta-analysis of available data. Moreover, we have explored portable devices to enhance ICH identification. While these devices have shown promise in detecting ICH, further technological development is required to distinguish between stroke subtypes (ICH vs ischaemic stroke) and non-stroke diagnoses.
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Affiliation(s)
- Mohammed Almubayyidh
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Department of Aviation and Marine, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Ibrahim Alghamdi
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Department of Emergency Medical Services, College of Applied Medical Sciences, Khamis Mushait Campus, King Khalid University, Abha, Saudi Arabia
| | - Adrian Robert Parry-Jones
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - David Jenkins
- Division of Informatics, Imaging and Data Science, The University of Manchester, Manchester, UK
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Kaffes M, Bondi F, Geisler F, Grittner U, Haacke L, Ihl T, Lorenz M, Schehadat MS, Schwabauer E, Wendt M, Zuber M, Kübler-Weller D, Lorenz-Meyer I, Sanchez JC, Montaner J, Audebert HJ, Weber JE. Optimization of sensitivity and specificity of a biomarker-based blood test (LVOCheck-Opti): A protocol for a multicenter prospective observational study of patients suspected of having a stroke. Front Neurol 2024; 14:1327348. [PMID: 38371304 PMCID: PMC10870936 DOI: 10.3389/fneur.2023.1327348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Introduction Acute ischemic stroke (AIS) is a time-critical medical emergency. For patients with large-vessel occlusions (LVO), mechanical thrombectomy (MT) is the gold-standard treatment. Mobile Stroke Units (MSUs) provide on-site diagnostic capabilities via computed tomography (CT) and have been shown to improve functional outcomes in stroke patients, but are cost-efficient only in urban areas. Blood biomarkers have recently emerged as possible alternative to cerebral imaging for LVO diagnosis. Prehospital LVO diagnosis offers the potential to transport patients directly to centers that have MT treatment available. In this study, we assess the accuracy of combining two biomarkers, HFABP and NT-proBNP, with clinical indicators to detect LVO using ultra-early prehospital blood samples. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00030399). Methods and analysis We plan a multicenter prospective observational study with 800 patients with suspected stroke enrolled within 24 h of symptom onset. Study participants will be recruited at three sites (MSUs) in Berlin, Germany. Blood-samples will be taken pre-hospitally at the scene and tested for HFABP and NT-proBNP levels. Additional clinical data and information on final diagnosis will be collected and documented in an electronic case report form (eCRF). Sensitivity and specificity of the combination will be calculated through iterative permutation-response calculations. Discussion This study aims to evaluate the diagnostic capabilities of a combination of the biomarkers HFABP and NT-proBNP in LVO prediction. In contrast to most other biomarker studies to date, by employing MSUs as study centers, ultra-early levels of biomarkers can be analyzed. Point-of-care LVO detection in suspected stroke could lead to faster treatment in both urban and rural settings and thus improve functional outcomes on a broader scale. Clinical trial registration Deutsches Register klinischer Studien https://drks.de/search/de/trial/DRKS00030399, DRKS00030399.
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Affiliation(s)
- Maximilian Kaffes
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Fulvio Bondi
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Frederik Geisler
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lisa Haacke
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Ihl
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maren Lorenz
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marc S. Schehadat
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eugen Schwabauer
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Martina Zuber
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dorothee Kübler-Weller
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jean-Charles Sanchez
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Joan Montaner
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
- Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Heinrich J. Audebert
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Joachim E. Weber
- Department of Neurology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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Brown JB, Schreiber M, Moore EE, Jenkins DH, Bank EA, Gurney JM. Commentary on gaps in prehospital trauma care: education and bioengineering innovations to improve outcomes in hemorrhage and traumatic brain injury. Trauma Surg Acute Care Open 2024; 9:e001122. [PMID: 38196935 PMCID: PMC10773423 DOI: 10.1136/tsaco-2023-001122] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/23/2023] [Indexed: 01/11/2024] Open
Abstract
Hemorrhage remains the leading cause of preventable death on the battlefield and the civilian arena. Many of these deaths occur in the prehospital setting. Traumatic brain injury also represents a major source of early mortality and morbidity in military and civilian settings. The inaugural HERETIC (HEmostatic REsuscitation and Trauma Induced Coagulopathy) Symposium convened a multidisciplinary panel of experts in prehospital trauma care to discuss what education and bioengineering advancements in the prehospital space are necessary to improve outcomes in hemorrhagic shock and traumatic brain injury. The panel identified several promising technological breakthroughs, including field point-of-care diagnostics for hemorrhage and brain injury and unique hemorrhage control options for non-compressible torso hemorrhage. Many of these technologies exist but require further advancement to be feasibly and reliably deployed in a prehospital or combat environment. The panel discussed shifting educational and training paradigms to clinical immersion experiences, particularly for prehospital clinicians. The panel discussed an important balance between pushing traditionally hospital-based interventions into the field and developing novel intervention options specifically for the prehospital environment. Advancing prehospital diagnostics may be important not only to allow more targeted applications of therapeutic options, but also to identify patients with less urgent injuries that may not need more advanced diagnostics, interventions, or transfer to a higher level of care in resource-constrained environments. Academia and industry should partner and prioritize some of the promising advances identified with a goal to prepare them for clinical field deployment to optimize the care of patients near the point of injury.
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Affiliation(s)
- Joshua B Brown
- Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Martin Schreiber
- Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Ernest E Moore
- Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado, USA
| | - Donald H Jenkins
- Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Eric A Bank
- Harris County Emergency Services District No 48, Katy, Texas, USA
| | - Jennifer M Gurney
- Defense Committees on Trauma, Joint Trauma System, JBSA Fort Sam Houston, San Antonio, Texas, USA
- Department of Surgery, San Antonio Military Health System, San Antonio, Texas, USA
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Rodríguez-Penedo A, Costa-Rama E, Fernández B, García-Cabo C, Benavente L, Calleja S, Fernández-Abedul MT, Pereiro R. Palladium nanoclusters as a label to determine GFAP in human serum from donors with stroke by bimodal detection: inductively coupled plasma-mass spectrometry and linear sweep voltammetry. Mikrochim Acta 2023; 190:493. [PMID: 38032374 PMCID: PMC10689531 DOI: 10.1007/s00604-023-06059-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023]
Abstract
Water-soluble, stable, and monodisperse palladium nanoclusters (PdNCs) were synthesized using NaBH4 as a reductant and lipoic acid as a ligand. PdNCs, measured by high-resolution transmission electron microscopy, showed a round shape and a diameter of 2.49 ± 0.02 nm. It was found that each PdNC contains 550 Pd atoms on average. These PdNCs offer high amplification as a label of biochemical reactions when inductively coupled plasma-mass spectrometry (ICP-MS) is used as a detector. In addition, PdNCs have catalytic activity on electrochemical reactions, allowing detection by linear sweep voltammetry (LSV). As a proof of applicability, a competitive immunoassay based on PdNC labels was developed for the determination of glial fibrillary acidic protein (GFAP) in human serum, comparing ICP-MS and LSV detection. GFAP is a biomarker for differentiating between patients with ischemic stroke (IS) and hemorrhagic stroke (HS). The limit of detection (LoD), corresponding to IC10 (4-parameter logistic curve), was 0.03 pM of GFAP, both by ICP-MS and LSV, being lower than the 0.31 pM LoD provided by the ELISA commercial kit. Using the error profile method, 0.03 pM and 0.11 pM LoDs were obtained respectively by ICP-MS and LSV: LoD is lower by ICP-MS due to the better precision of the measurements. The analyses of human serum samples from IS, HS, and control (CT) donors using PdNC labels and detection by ICP-MS and LSV were validated with a commercial ELISA kit (for CT donors only ICP-MS provided enough sensitivity). Results point out toward the future use of PdNCs as a label in other immunoprobes for the determination of specific proteins requiring very low LoDs as well as the development of electrochemical decentralized methodologies.
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Affiliation(s)
- Alejandro Rodríguez-Penedo
- Department of Physical and Analytical Chemistry, University of Oviedo, Julian Clavería 8, 33006, Oviedo, Spain
| | - Estefanía Costa-Rama
- Department of Physical and Analytical Chemistry, University of Oviedo, Julian Clavería 8, 33006, Oviedo, Spain
| | - Beatriz Fernández
- Department of Physical and Analytical Chemistry, University of Oviedo, Julian Clavería 8, 33006, Oviedo, Spain.
| | - Carmen García-Cabo
- Department of Neurology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Lorena Benavente
- Department of Neurology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Sergio Calleja
- Department of Neurology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - M Teresa Fernández-Abedul
- Department of Physical and Analytical Chemistry, University of Oviedo, Julian Clavería 8, 33006, Oviedo, Spain.
| | - Rosario Pereiro
- Department of Physical and Analytical Chemistry, University of Oviedo, Julian Clavería 8, 33006, Oviedo, Spain
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Florijn BW, Leontien van der Bent M, Nguyen TMT, Quax PHA, Wermer MJH, Yaël Nossent A, Kruyt ND. Non-coding RNAs versus protein biomarkers to diagnose and differentiate acute stroke: Systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107388. [PMID: 37778160 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/16/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Stroke diagnosis is dependent on lengthy clinical and neuroimaging assessments, while rapid treatment initiation improves clinical outcome. Currently, more sensitive biomarker assays of both non-coding RNA- and protein biomarkers have improved their detectability, which could accelerate stroke diagnosis. This systematic review and meta-analysis compares non-coding RNA- with protein biomarkers for their potential to diagnose and differentiate acute stroke (subtypes) in (pre-)hospital settings. METHODS We performed a systematic review and meta-analysis of studies evaluating diagnostic performance of non-coding RNA- and protein biomarkers to differentiate acute ischemic and hemorrhagic stroke, stroke mimics, and (healthy) controls. Quality appraisal of individual studies was assessed using the QUADAS-2 tool while the meta-analysis was performed with the sROC approach and by assessing pooled sensitivity and specificity, diagnostic odds ratios, positive- and negative likelihood ratios, and the Youden Index. SUMMARY OF REVIEW 112 studies were included in the systematic review and 42 studies in the meta-analysis containing 11627 patients with ischemic strokes, 2110 patients with hemorrhagic strokes, 1393 patients with a stroke mimic, and 5548 healthy controls. Proteins (IL-6 and S100 calcium-binding protein B (S100B)) and microRNAs (miR-30a) have similar performance in ischemic stroke diagnosis. To differentiate between ischemic- or hemorrhagic strokes, glial fibrillary acidic protein (GFAP) levels and autoantibodies to the NR2 peptide (NR2aAb, a cleavage product of NMDA neuroreceptors) were best performing whereas no investigated protein or non-coding RNA biomarkers differentiated stroke from stroke mimics with high diagnostic potential. CONCLUSIONS Despite sampling time differences, circulating microRNAs (< 24 h) and proteins (< 4,5 h) perform equally well in ischemic stroke diagnosis. GFAP differentiates stroke subtypes, while a biomarker panel of GFAP and UCH-L1 improved the sensitivity and specificity of UCH-L1 alone to differentiate stroke.
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Affiliation(s)
- Barend W Florijn
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, the Netherlands.
| | - M Leontien van der Bent
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands; Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, the Netherlands
| | - Truc My T Nguyen
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul H A Quax
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands; Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - A Yaël Nossent
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands; Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Department of Neurology Institution, Leiden University Medical Center, Leiden/The Hague, Zuid Holland, The Netherlands
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Lv XN, Li ZQ, Li Q. Blood-Based Biomarkers in Intracerebral Hemorrhage. J Clin Med 2023; 12:6562. [PMID: 37892701 PMCID: PMC10607631 DOI: 10.3390/jcm12206562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
Intracerebral hemorrhage (ICH) is one of the most lethal subtypes of stroke, associated with high morbidity and mortality. Prevention of hematoma growth and perihematomal edema expansion are promising therapeutic targets currently under investigation. Despite recent improvements in the management of ICH, the ideal treatments are still to be determined. Early stratification and triage of ICH patients enable the adjustment of the standard of care in keeping with the personalized medicine principles. In recent years, research efforts have been concentrated on the development and validation of blood-based biomarkers. The benefit of looking for blood candidate markers is obvious because of their acceptance in terms of sample collection by the general population compared to any other body fluid. Given their ease of accessibility in clinical practice, blood-based biomarkers have been widely used as potential diagnostic, predictive, and prognostic markers. This review identifies some relevant and potentially promising blood biomarkers for ICH. These blood-based markers are summarized by their roles in clinical practice. Well-designed and large-scale studies are required to validate the use of all these biomarkers in the future.
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Affiliation(s)
- Xin-Ni Lv
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; (X.-N.L.); (Z.-Q.L.)
| | - Zuo-Qiao Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; (X.-N.L.); (Z.-Q.L.)
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; (X.-N.L.); (Z.-Q.L.)
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
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Neves D, Salazar IL, Almeida RD, Silva RM. Molecular mechanisms of ischemia and glutamate excitotoxicity. Life Sci 2023; 328:121814. [PMID: 37236602 DOI: 10.1016/j.lfs.2023.121814] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/05/2023] [Accepted: 05/23/2023] [Indexed: 05/28/2023]
Abstract
Excitotoxicity is classically defined as the neuronal damage caused by the excessive release of glutamate, and subsequent activation of excitatory plasma membrane receptors. In the mammalian brain, this phenomenon is mainly driven by excessive activation of glutamate receptors (GRs). Excitotoxicity is common to several chronic disorders of the Central Nervous System (CNS) and is considered the primary mechanism of neuronal loss of function and cell death in acute CNS diseases (e.g. ischemic stroke). Multiple mechanisms and pathways lead to excitotoxic cell damage including pro-death signaling cascade events downstream of glutamate receptors, calcium (Ca2+) overload, oxidative stress, mitochondrial impairment, excessive glutamate in the synaptic cleft as well as altered energy metabolism. Here, we review the current knowledge on the molecular mechanisms that underlie excitotoxicity, emphasizing the role of Nicotinamide Adenine Dinucleotide (NAD) metabolism. We also discuss novel and promising therapeutic strategies to treat excitotoxicity, highlighting recent clinical trials. Finally, we will shed light on the ongoing search for stroke biomarkers, an exciting and promising field of research, which may improve stroke diagnosis, prognosis and allow better treatment options.
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Affiliation(s)
- Diogo Neves
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Ivan L Salazar
- Multidisciplinary Institute of Ageing, MIA - Portugal, University of Coimbra, Coimbra, Portugal
| | - Ramiro D Almeida
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal; CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal.
| | - Raquel M Silva
- iBiMED - Institute of Biomedicine, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal; Universidade Católica Portuguesa, Faculdade de Medicina Dentária, Centro de Investigação Interdisciplinar em Saúde, Viseu, Portugal.
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di Biase L, Bonura A, Pecoraro PM, Carbone SP, Di Lazzaro V. Unlocking the Potential of Stroke Blood Biomarkers: Early Diagnosis, Ischemic vs. Haemorrhagic Differentiation and Haemorrhagic Transformation Risk: A Comprehensive Review. Int J Mol Sci 2023; 24:11545. [PMID: 37511304 PMCID: PMC10380631 DOI: 10.3390/ijms241411545] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Stroke, a complex and heterogeneous disease, is a leading cause of morbidity and mortality worldwide. The timely therapeutic intervention significantly impacts patient outcomes, but early stroke diagnosis is challenging due to the lack of specific diagnostic biomarkers. This review critically examines the literature for potential biomarkers that may aid in early diagnosis, differentiation between ischemic and hemorrhagic stroke, and prediction of hemorrhagic transformation in ischemic stroke. After a thorough analysis, four promising biomarkers were identified: Antithrombin III (ATIII), fibrinogen, and ischemia-modified albumin (IMA) for diagnostic purposes; glial fibrillary acidic protein (GFAP), micro RNA 124-3p, and a panel of 11 metabolites for distinguishing between ischemic and hemorrhagic stroke; and matrix metalloproteinase-9 (MMP-9), s100b, and interleukin 33 for predicting hemorrhagic transformation. We propose a biomarker panel integrating these markers, each reflecting different pathophysiological stages of stroke, that could significantly improve stroke patients' early detection and treatment. Despite promising results, further research and validation are needed to demonstrate the clinical utility of this proposed panel for routine stroke treatment.
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Affiliation(s)
- Lazzaro di Biase
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy
- Brain Innovations Lab, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Adriano Bonura
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy
- Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Pasquale Maria Pecoraro
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy
- Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Simona Paola Carbone
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy
- Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Vincenzo Di Lazzaro
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy
- Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
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Geisler F, Haacke L, Lorenz M, Schwabauer E, Wendt M, Bernhardt L, Dashti E, Freitag E, Kunz A, Hofmann-Shen C, Zuber M, Waldschmidt C, Kandil FI, Kappert K, Dang-Heine C, Lorenz-Meyer I, Audebert HJ, Weber JE. Prospective collection of blood plasma samples to identify potential biomarkers for the prehospital stroke diagnosis (ProGrEss-Bio): study protocol for a multicenter prospective observational study. Front Neurol 2023; 14:1201130. [PMID: 37483444 PMCID: PMC10359480 DOI: 10.3389/fneur.2023.1201130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/09/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are well-established, evidence-based, time-critical therapies that reduce morbidity and mortality in acute ischemic stroke (AIS) patients. The exclusion of intracerebral hemorrhage (ICH) is mandatory and has been performed by cerebral imaging to date. Mobile stroke units (MSUs) have been shown to improve functional outcomes by bringing cerebral imaging and IVT directly to the patient, but they have limited coverage. Blood biomarkers clearly distinguishing between AIS, ICH, and stroke mimics (SM) could provide an alternative to cerebral imaging if concentration changes are detectable in the hyperacute phase after stroke with high diagnostic accuracy. In this study, we will take blood samples in a prehospital setting to evaluate potential biomarkers. The study was registered in the German Clinical Trials Register (https://drks.de/search/de) with the identifier DRKS00023063. Methods and analysis We plan a prospective, observational study involving 300 patients with suspected stroke and symptom onset of ≤4.5 h before the collection of biomarkers. Study participants will be recruited from three sites in Berlin, Germany during MSU deployments. The focus of the study is the collection of blood samples from participants at the prehospital scene and from participants with AIS or ICH at a second-time point. All samples will be analyzed using targeted and untargeted analytical approaches. Study-related information about participants, including medical information and discharge diagnoses from the subsequent treating hospital, will be collected and documented in an electronic case report form (eCRF). Discussion This study will evaluate whether a single blood biomarker or a combination of biomarkers can distinguish patients with AIS and ICH from patients with stroke and SM in the early phase after symptom onset in the prehospital setting. In addition, the kinetics of blood biomarkers in AIS and ICH patients will be investigated. Our goal is to evaluate new ways to reliably diagnose stroke in the prehospital setting and thus accelerate the application of evidence-based therapies to stroke patients.
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Affiliation(s)
- Frederik Geisler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lisa Haacke
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maren Lorenz
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eugen Schwabauer
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Lydia Bernhardt
- Department of Neurology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Eman Dashti
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Erik Freitag
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Kunz
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christina Hofmann-Shen
- Kliniken Beelitz, Teaching Hospital of Brandenburg Medical School Theodor Fontane, Beelitz-Heilstätten, Germany
| | - Martina Zuber
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Farid I. Kandil
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kai Kappert
- Institute of Diagnostic Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Chantip Dang-Heine
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Lorenz-Meyer
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Heinrich J. Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Joachim E. Weber
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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10
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Delgardo M, Rabin G, Tudor T, Tang AJ, Reeves G, Connolly ES. Monitoring risk and preventing ischemic stroke in the very old. Expert Rev Neurother 2023; 23:791-801. [PMID: 37540092 DOI: 10.1080/14737175.2023.2244674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Stroke is a significant cause of death, and the leading cause of severe long-term disability for individuals over 80 (the very old), yet few studies of such risk factors for ischemic stroke, or the known mitigation techniques, in this population, and the evidence base regarding risk modification strategies in this susceptible population can be inconsistent and incomplete. This article examines current guidelines and evidence regarding medical management, lifestyle changes, and psychosocial interactions that can contribute to the primary and secondary prevention of ischemic stroke in the very old. AREAS COVERED The authors conducted a literature search for ischemic stroke prevention and risk assessment in the elderly via PubMed. Furthermore, they describe current strategies for monitoring risk and preventing ischemic stroke in the elderly population. EXPERT OPINION Ischemic stroke poses a significant health risk to the elderly, with prevention relying on managing modifiable risk factors such as hypertension, atrial fibrillation, diabetes, and high cholesterol, as well as promoting healthy lifestyle choices like quitting smoking, regular physical activity and a heart-healthy diet. Healthcare providers must adopt a multifaceted approach, addressing individual and population-level factors while remaining vigilant in monitoring and managing risk factors to reduce the incidence and impact of stroke in older adults.
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Affiliation(s)
- Mychael Delgardo
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Grant Rabin
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Thilan Tudor
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Anthony J Tang
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Geoffrey Reeves
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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11
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Kowalski RG, Ledreux A, Violette JE, Neumann RT, Ornelas D, Yu X, Griffiths SG, Lewis S, Nash P, Monte AA, Coughlan CM, Deighan C, Grotta JC, Jones WJ, Graner MW. Rapid Activation of Neuroinflammation in Stroke: Plasma and Extracellular Vesicles Obtained on a Mobile Stroke Unit. Stroke 2023; 54:e52-e57. [PMID: 36727508 PMCID: PMC10052772 DOI: 10.1161/strokeaha.122.041422] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/16/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Neuroinflammation is ubiquitous in acute stroke and worsens outcome. However, the precise timing of the inflammatory response is unknown, hindering the design of acute anti-inflammatory therapeutic interventions. We sought to identify the onset of the neuroinflammatory cascade using a mobile stroke unit. METHODS The study is a proof-of-concept, cohort investigation of ultra-early blood- and extracellular vesicle-derived markers of neuroinflammation and outcome in acute stroke. Blood was obtained, prehospital, on an mobile stroke unit. Outcomes were biomarker concentrations, modified Rankin Scale score, and National Institutes of Health Stroke Scale score. RESULTS Forty-one adults were analyzed, including 15 patients treated on the mobile stroke unit between August 2021 and April 2022, and 26 healthy controls to establish biomarker reference levels. Median patient age was 74 (range, 36-97) years, 60% were female, and 80% White. Ten (67%) were diagnosed as stroke, with 8 (53%) confirmed and 2 likely transient ischemic attack or stroke averted by thrombolysis; 5 were stroke mimics. For strokes, median initial National Institutes of Health Stroke Scale score was 11 (range, 4-19) and 6 (75%) received tPA (tissue-type plasminogen activator). Blood was obtained a median of 58 (range, 36-133) minutes after symptom onset. Within 36 minutes after stroke, plasma IL-6 (interleukin-6), neurofilament light chain, UCH-L1 (ubiquitin C-terminal hydrolase L1), and GFAP (glial fibrillary acidic protein) were elevated by as much as 10 times normal. In EVs, MMP-9 (matrix metalloproteinase-9), CXCL4 (chemokine (C-X-C motif) ligand 4), CRP (C-reactive protein), IL-6, OPN (osteopontin), and PECAM1 (platelet and endothelial cell adhesion molecule 1) were elevated. Inflammatory markers increased rapidly in the first 2 hours and continued rising for 24 hours. CONCLUSIONS The neuroinflammatory cascade was found to be activated within 36 to 133 minutes after stroke and progresses rapidly. This is earlier than observed previously in humans and suggests injury from neuroinflammation occurs faster than had been surmised. These findings could inform development of acute immunomodulatory stroke therapies and lead to new diagnostic tools and improved outcomes.
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Affiliation(s)
- Robert G Kowalski
- Department of Neurosurgery (R.G.K., A.L., R.T.N., X.Y., M.W.G.)
- Department of Neurology (RGK, CMC, WJJ)
| | - Aurélie Ledreux
- Department of Neurosurgery (R.G.K., A.L., R.T.N., X.Y., M.W.G.)
| | - John E Violette
- UCHealth, University of Colorado Hospital, Aurora (J.E.V., D.O.)
| | | | - David Ornelas
- UCHealth, University of Colorado Hospital, Aurora (J.E.V., D.O.)
| | - Xiaoli Yu
- Department of Neurosurgery (R.G.K., A.L., R.T.N., X.Y., M.W.G.)
| | | | | | | | - Andrew A Monte
- Department of Emergency Medicine (A.A.M.)
- University of Colorado School of Medicine, Aurora (A.A.M.)
| | | | | | - James C Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston (J.C.G.)
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12
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Kedžo J, Domjanović Škopinić T, Domjanović J, Marinović Guić M, Lovrić Kojundžić S, Tandara L, Matetić A, Jurišić Z. Neurologic Biomarkers, Neuroimaging, and Cognitive Function in Persistent Atrial Fibrillation: A Cross-Sectional Study. Int J Mol Sci 2023; 24:ijms24032902. [PMID: 36769225 PMCID: PMC9918133 DOI: 10.3390/ijms24032902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 01/28/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to evaluate the specific neurologic biomarkers, neuroimaging findings, and cognitive function in patients with persistent atrial fibrillation (AF) undergoing electrical cardioversion, compared to control subjects. This cross-sectional study included 25 patients with persistent AF undergoing electrical cardioversion and 16 age- and sex-matched control subjects. Plasma levels of glial fibrillary acidic protein (GFAP), neurofilament light protein (NFL), and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1), as well as parameters of neuroimaging and cognitive function, were compared between the groups. Neuroimaging was performed using the standard magnetic resonance imaging (MRI) protocol. Cognitive function was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function Index. Further analysis of neurologic biomarkers was performed based on the subsequent electrical cardioversion. There was no significant difference in GFAP (median of 24.7 vs. 28.7 pg/mL, p = 0.347), UCH-L1 (median of 112.8 vs. 117.7 pg/mL, p = 0.885), and NFL (median of 14.2 vs. 15.4 pg/mL, p = 0.886) levels between AF patients and control subjects. Similarly, neuroimaging showed no between-group difference in large cortical and non-cortical lesions (n = 2, 8.0% vs. n = 0, 0.0%, p = 0.246), small non-cortical lesions (n = 5, 20.0% vs. n = 5, 31.3%, p = 0.413), white matter hyperintensity (n = 23, 92.0% vs. n = 14, 87.5%, p = 0.636), and thromboembolic lesions (n = 0, 0.0% vs. n = 1, 6.3%, p = 0.206). Cognitive assessment did not show any between-group difference in the PROMIS index (52.2 ± 9.6 vs. 51.2 ± 6.2, p = 0.706). Finally, there were no significant dynamics in neurologic biomarkers following electrical cardioversion (p > 0.05). This hypothesis-generating study did not find a significant difference in neurologic biomarkers, neuroimaging findings, or cognitive function between patients with persistent AF and controls. The restoration of sinus rhythm was not significantly associated with a change in neurologic biomarkers. Further powered longitudinal studies are needed to re-assess these findings in an AF population.
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Affiliation(s)
- Josip Kedžo
- Department of Cardiology, University Hospital of Split, 21000 Split, Croatia
- Correspondence:
| | | | - Josipa Domjanović
- Department of Nephrology, University Hospital of Split, 21000 Split, Croatia
| | - Maja Marinović Guić
- Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia
- School of Medicine, University of Split, 21000 Split, Croatia
| | - Sanja Lovrić Kojundžić
- Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia
- School of Medicine, University of Split, 21000 Split, Croatia
| | - Leida Tandara
- Medical Biochemistry and Laboratory Medicine Subdivision, Medical Laboratory Diagnostic Division, University Hospital of Split, 21000 Split, Croatia
| | - Andrija Matetić
- Department of Cardiology, University Hospital of Split, 21000 Split, Croatia
| | - Zrinka Jurišić
- Department of Cardiology, University Hospital of Split, 21000 Split, Croatia
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13
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Jæger HS, Tranberg D, Larsen K, Valentin JB, Blauenfeldt RA, Luger S, Bache KG, Gude MF. Diagnostic performance of Glial Fibrillary Acidic Protein and Prehospital Stroke Scale for identification of stroke and stroke subtypes in an unselected patient cohort with symptom onset < 4.5 h. Scand J Trauma Resusc Emerg Med 2023; 31:1. [PMID: 36604741 PMCID: PMC9814331 DOI: 10.1186/s13049-022-01065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 12/26/2022] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Rapid identification and treatment of stroke is crucial for the outcome of the patient. We aimed to determine the performance of glial fibrillary acidic protein (GFAP) independently and in combination with the Prehospital Stroke Score (PreSS) for identification and differentiation of acute stroke within 4.5 h after symptom onset. PATIENTS AND METHODS Clinical data and serum samples were collected from the Treat-Norwegian Acute Stroke Prehospital Project (Treat-NASPP). Patients with suspected stroke and symptoms lasting ≤ 4.5 h had blood samples collected and were evaluated with the National Institutes of Health Stroke Scale prospectively. In this sub study, NIHSS was retrospectively translated into PreSS and GFAP was measured using the sensitive single molecule array (SIMOA). RESULTS A total of 299 patients with suspected stroke were recruited from Treat-NASPP and included in this study (44% acute ischemic stroke (AIS), 10% intracranial hemorrhage (ICrH), 7% transient ischemic attack (TIA), and 38% stroke mimics). ICrH was identified with a cross-fold validated area under the receiver-operating characteristic curve (AUC) of 0.73 (95% CI 0.62-0.84). A decision tree with PreSS and GFAP combined, first identified patients with a low probability of stroke. Subsequently, GFAP detected patients with ICrH with a 25.0% sensitivity (95% CI 11.5-43.4) and 100.0% specificity (95% CI 98.6-100.0). Lastly, patients with large-vessel occlusion (LVO) were detected with a 55.6% sensitivity (95% CI 35.3-74.5) and 82.4% specificity (95% CI 77.3-86.7). CONCLUSION In unselected patients with suspected stroke, GFAP alone identified ICrH. Combined in a decision tree, GFAP and PreSS identified subgroups with high proportions of stroke mimics, ICrH, LVO, and AIS (non-LVO strokes).
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Affiliation(s)
- Henriette S. Jæger
- grid.420120.50000 0004 0481 3017The Norwegian Air Ambulance Foundation, Research and Development, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Ditte Tranberg
- grid.425869.40000 0004 0626 6125Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, Olof Palmes Allé 34, 2., 8200 Aarhus N, Denmark
| | - Karianne Larsen
- grid.420120.50000 0004 0481 3017The Norwegian Air Ambulance Foundation, Research and Development, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Jan B. Valentin
- grid.5117.20000 0001 0742 471XDanish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Rolf A. Blauenfeldt
- grid.154185.c0000 0004 0512 597XDepartment of Neurology and Danish Stroke Center, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Sebastian Luger
- grid.411088.40000 0004 0578 8220Department of Neurology, University Hospital Frankfurt/Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kristi G. Bache
- grid.5510.10000 0004 1936 8921Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway ,grid.446040.20000 0001 1940 9648Research and Dissemination, Østfold University College, Halden, Norway
| | - Martin F. Gude
- grid.425869.40000 0004 0626 6125Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region and Aarhus University, Olof Palmes Allé 34, 2., 8200 Aarhus N, Denmark
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14
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Sayad A, Uddin SM, Yao S, Wilson H, Chan J, Zhao H, Donnan G, Davis S, Skafidas E, Yan B, Kwan P. A magnetoimpedance biosensor microfluidic platform for detection of glial fibrillary acidic protein in blood for acute stroke classification. Biosens Bioelectron 2022; 211:114410. [PMID: 35617799 DOI: 10.1016/j.bios.2022.114410] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/15/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022]
Abstract
Acute stroke is the third leading cause of mortality and disability worldwide. Administration of appropriate therapy for acute stroke is critically dependent on timely classification into either ischemic or hemorrhagic subtypes, which have divergent treatment pathways. The current classification method is based on neuroimaging, which generally requires the transport of the patient to a hospital-based facility unless a mobile stroke unit is available. Plasma glial fibrillary acidic protein (GFAP) level has been identified as a useful blood-based biomarker to differentiate stroke subtypes. However, its conventional immunoassay methods are laboratory-based and time-consuming. Novel approaches for rapid stroke classification near the patients are urgently needed. Here, we report the development and testing of a microfluidic-based magnetoimpedance biosensor platform for measuring GFAP levels. The platform consists of a microfluidic chip for GFAP extraction from a blood sample and a magnetoimpedance (MI) biosensor that employs Dynabeads as a magnetic label to capture the GFAP molecules. We demonstrated the detection of recombinant GFAP protein in phosphate-buffered saline (PBS) and in mouse blood samples (detection limit 0.01 ng/mL) and of physiological GFAP in blood and plasma samples (detection limit 1.0 ng/mL) obtained from acute stroke patients. This detection level is within the range of cut-off levels required for clinical stroke subtype differentiation. This platform has the potential to be incorporated into a small device with further development to assist in the classification of acute stroke patients and clinical decision-making at the point-of-care.
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Affiliation(s)
- Abkar Sayad
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, 3004, Australia.
| | - Shah Mukim Uddin
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia.
| | - Scarlett Yao
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia.
| | - Harold Wilson
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia. https://
| | - Jianxiong Chan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, 3004, Australia; Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia.
| | - Henry Zhao
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia; Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, VIC, 3010, Australia.
| | - Geoffrey Donnan
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia; Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, VIC, 3010, Australia.
| | - Stephen Davis
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia; Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, VIC, 3010, Australia. https://
| | - Efstratios Skafidas
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia; Department of Electrical and Electronic Engineering, Melbourne School of Engineering, The University of Melbourne, VIC, 3010, Australia.
| | - Bernard Yan
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia; Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, VIC, 3010, Australia.
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, 3004, Australia; Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC, 3050, Australia; Department of Electrical and Electronic Engineering, Melbourne School of Engineering, The University of Melbourne, VIC, 3010, Australia; Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, VIC, 3010, Australia.
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15
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Ebinger M, Audebert HJ. Shifting acute stroke management to the prehospital setting. Curr Opin Neurol 2022; 35:4-9. [PMID: 34799513 DOI: 10.1097/wco.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The earlier the treatment, the better the outcomes after acute ischemic stroke. Optimizing prehospital care bears potential to shorten treatment times. We here review the recent literature on mothership vs. drip-and-ship as well as mobile stroke unit concepts. RECENT FINDINGS Mobile stroke units result in the shortest onset-to-treatment times in mostly urban settings. SUMMARY Future research should focus on further streamlining processes around mobile stroke units, especially improving dispatch algorithms and improve referral for endovascular therapy.
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Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
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16
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Karakus A, Girerd N, Sanchez JC, Sabben C, Wietrich A, Lavandier K, Marchal S, Aubertin A, Humbertjean L, Mione G, Bouali S, Duarte K, Reymond S, Gory B, Richard S. Identifying patients with cerebral infarction within the time window compatible with reperfusion therapy, diagnostic performance of glutathione S-transferase-π (GST-π) and peroxiredoxin 1 (PRDX1): exploratory prospective multicentre study FLAG-1 protocol. BMJ Open 2021; 11:e046167. [PMID: 34417212 PMCID: PMC8381327 DOI: 10.1136/bmjopen-2020-046167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Plasma biomarkers may be useful in diagnosing acute cerebral infarction requiring urgent reperfusion, but their performance remains to be confirmed. If confirmed, these molecules could be used to develop rapid and reliable decentralised measurement methods, making it possible to initiate reperfusion therapy before hospital admission. The FLAG-1 large prospective study will constitute a plasma bank to assess the diagnostic performance of two biomarkers: glutathione S-transferase-π and peroxiredoxin 1. These molecules are involved in the oxidative stress response and could identify cerebral infarction within a therapeutic window of less than 4.5 hours following the onset of symptoms. Secondary objectives include assessing performance of these biomarkers within 3-hour and 6-hour windows; identifying additional biomarkers diagnosing cerebral infarction and significant criteria guiding therapeutic decisions: ischaemic features of stroke, presence of diffusion/fluid-attenuated inversion recovery mismatch, volume of cerebral infarction and penumbra on cerebral MRI. METHODS AND ANALYSIS The exploratory, prospective, multicentre FLAG-1 Study will include 945 patients with acute stroke symptoms (onset ≤12 hours, National Institute of Health Stroke Scale score ≥3). Each patient's 25 mL blood sample will be associated with cerebral MRI data. Two patient groups will be defined based on the time of blood collection (before and after 4.5 hours following onset). Receiver operating characteristic analysis will determine the diagnostic performance of each biomarker, alone or in combination, for the identification of cerebral infarction <4.5 hours. ETHICS AND DISSEMINATION The protocol has been approved by an independent ethics committee. Biological samples are retained in line with best practices and procedures, in accordance with French legislation. Anonymised data and cerebral imaging records are stored using electronic case report forms and a secure server, respectively, registered with the French Data Protection Authority (Commission Nationale de l'Informatique et des Libertés (CNIL)). Results will be disseminated through scientific meetings and publication in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03364296).
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Affiliation(s)
- Arif Karakus
- Department of Neurology, Stroke Unit, University Hospital Centre Nancy, 54035 Nancy, France
- University of Lorraine, Nancy, France
| | - Nicolas Girerd
- University of Lorraine, Nancy, France
- Plurithematic Clinical Investigation Center, CIC-P 1433, INSERM U1116, University Hospital Centre Nancy, 54500 Vandoeuvre-lès-Nancy, France
| | - Jean-Charles Sanchez
- Department of Human Protein Sciences, University of Geneva Medical Centre, 1206 Geneva, Switzerland
| | | | - Anthony Wietrich
- Stroke Unit, Bar-le-Duc Hospital Centre, 55000 Bar-le-Duc, France
| | - Karine Lavandier
- Stroke Unit, Bar-le-Duc Hospital Centre, 55000 Bar-le-Duc, France
| | - Sophie Marchal
- Stroke Unit, Verdun Hospital Centre, 55100 Verdun, France
| | - Anne Aubertin
- Stroke Unit, Hospital Centre Troyes, CS 20718, 10003 Troyes, France
| | - Lisa Humbertjean
- Department of Neurology, Stroke Unit, University Hospital Centre Nancy, 54035 Nancy, France
| | - Gioia Mione
- Department of Neurology, Stroke Unit, University Hospital Centre Nancy, 54035 Nancy, France
| | - Sanae Bouali
- Plurithematic Clinical Investigation Center, CIC-P 1433, INSERM U1116, University Hospital Centre Nancy, 54500 Vandoeuvre-lès-Nancy, France
| | - Kevin Duarte
- Plurithematic Clinical Investigation Center, CIC-P 1433, INSERM U1116, University Hospital Centre Nancy, 54500 Vandoeuvre-lès-Nancy, France
| | - Sandrine Reymond
- Department of Human Protein Sciences, University of Geneva Medical Centre, 1206 Geneva, Switzerland
| | - Benjamin Gory
- University of Lorraine, Nancy, France
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, IADI, University Hospital Centre Nancy, 54035 Nancy, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, University Hospital Centre Nancy, 54035 Nancy, France
- University of Lorraine, Nancy, France
- Plurithematic Clinical Investigation Center, CIC-P 1433, INSERM U1116, University Hospital Centre Nancy, 54500 Vandoeuvre-lès-Nancy, France
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17
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Mattila OS, Ashton NJ, Blennow K, Zetterberg H, Harve-Rytsälä H, Pihlasviita S, Ritvonen J, Sibolt G, Nukarinen T, Curtze S, Strbian D, Pystynen M, Tatlisumak T, Kuisma M, Lindsberg PJ. Ultra-Early Differential Diagnosis of Acute Cerebral Ischemia and Hemorrhagic Stroke by Measuring the Prehospital Release Rate of GFAP. Clin Chem 2021; 67:1361-1372. [PMID: 34383905 DOI: 10.1093/clinchem/hvab128] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/11/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Plasma glial fibrillary acidic protein (GFAP) and tau are promising markers for differentiating acute cerebral ischemia (ACI) and hemorrhagic stroke (HS), but their prehospital dynamics and usefulness are unknown. METHODS We performed ultra-sensitivite single-molecule array (Simoa®) measurements of plasma GFAP and total tau in a stroke code patient cohort with cardinal stroke symptoms [National Institutes of Health Stroke Scale (NIHSS) ≥3]. Sequential sampling included 2 ultra-early samples, and a follow-up sample on the next morning. RESULTS We included 272 cases (203 ACI, 60 HS, and 9 stroke mimics). Median (IQR) last-known-well to sampling time was 53 (35-90) minutes for initial prehospital samples, 90 (67-130) minutes for secondary acute samples, and 21 (16-24) hours for next morning samples. Plasma GFAP was significantly higher in patients with HS than ACI (P < 0.001 for <1 hour and <3 hour prehospital samples, and <3 hour secondary samples), while total tau showed no intergroup difference. The prehospital GFAP release rate (pg/mL/minute) occurring between the 2 very early samples was significantly higher in patients with HS than ACI [2.4 (0.6-14.1)] versus 0.3 (-0.3-0.9) pg/mL/minute, P < 0.001. For cases with <3 hour prehospital sampling (ACI n = 178, HS n = 59), a combined rule (prehospital GFAP >410 pg/mL, or prehospital GFAP 90-410 pg/mL together with GFAP release >0.6 pg/mL/minute) enabled ruling out HS with high certainty (NPV 98.4%) in 68% of patients with ACI (sensitivity for HS 96.6%, specificity 68%, PPV 50%). CONCLUSIONS In comparison to single-point measurement, monitoring the prehospital GFAP release rate improves ultra-early differentiation of stroke subtypes. With serial measurement GFAP has potential to improve future prehospital stroke diagnostics .
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Affiliation(s)
- Olli S Mattila
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nicholas J Ashton
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,NIHR Biomedical Research Centre for Mental Health and Biomedical Research Unit for Dementia at South London and Maudsley NHS Foundation, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Heini Harve-Rytsälä
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Saana Pihlasviita
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juhani Ritvonen
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Gerli Sibolt
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tiina Nukarinen
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sami Curtze
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Daniel Strbian
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Pystynen
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience/Neurology, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Markku Kuisma
- Emergency Medicine and Services, Department of Emergency Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Perttu J Lindsberg
- Neurology and Clinical Neurosciences, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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18
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Abstract
Ischemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.
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Affiliation(s)
- Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center-Houston, Houston, Texas
| | - James C Grotta
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
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19
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Intracerebral Hemorrhage with Intraventricular Extension Associated with Loss of Consciousness at Symptom Onset. Neurocrit Care 2021; 35:418-427. [PMID: 33479920 PMCID: PMC8578176 DOI: 10.1007/s12028-020-01180-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/15/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND In patients with spontaneous intracerebral hemorrhage (ICH), pre-hospital markers of disease severity might be useful to potentially triage patients to undergo early interventions. OBJECTIVE Here, we tested whether loss of consciousness (LOC) at the onset of ICH is associated with intraventricular hemorrhage (IVH) on brain computed tomography (CT). METHODS Among 3000 ICH cases from ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage study, NS069763), we included patients with complete ICH/IVH volumetric CT measurements and excluded those with seizures at ICH onset. Trained investigators extracted data from medical charts. Mental status at symptom onset (categorized as alert/oriented, alert/confused, drowsy/somnolent, coma/unresponsive/posturing) and 3-month disability (modified Rankin score, mRS) were assessed through standardized interviews of participants or dedicated proxies. We used logistic regression and mediation analysis to assess relationships between LOC, IVH, and unfavorable outcome (mRS 4-6). RESULTS Two thousand seven hundred and twenty-four patients met inclusion criteria. Median admission Glasgow Coma Score was 15 (interquartile range 11-15). 46% had IVH on admission or follow-up CT. Patients with LOC (mental status: coma/unresponsive, n = 352) compared to those without LOC (all other mental status, n = 2372) were younger (60 vs. 62 years, p = 0.005) and had greater IVH frequency (77 vs. 41%, p < 0.001), greater peak ICH volumes (28 vs. 11 ml, p < 0.001), greater admission systolic blood pressure (200 vs. 184 mmHg, p < 0.001), and greater admission serum glucose (158 vs. 127 mg/dl, p < 0.001). LOC was independently associated with IVH presence (odds ratio, OR, 2.6, CI 1.9-3.5) and with unfavorable outcome (OR 3.05, CI 1.96-4.75). The association between LOC and outcome was significantly mediated by IVH (beta = 0.24, bootstrapped CI 0.17-0.32). CONCLUSION LOC at ICH onset may be a useful pre-hospital marker to identify patients at risk of having or developing IVH.
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20
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Cabezas JA, Bustamante A, Giannini N, Pecharroman E, Katsanos AH, Tsivgoulis G, Rozanski M, Audebert H, Mondello S, Llombart V, Montaner J. Discriminative value of glial fibrillar acidic protein (GFAP) as a diagnostic tool in acute stroke. Individual patient data meta-analysis. J Investig Med 2020; 68:1379-1385. [PMID: 32907910 DOI: 10.1136/jim-2020-001432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 01/30/2023]
Abstract
Glial fibrillar acidic protein (GFAP) in serum has been evaluated as a promising biomarker to differentiate between intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS). We assessed its value as diagnostic and prognostic tool for ICH through a literature systematic review and individual patient data (IPD) meta-analysis.We performed a systematic search in PubMed database until November 2018 for publications that evaluated GFAP to differentiate AIS and ICH within 4.5 hours after symptoms onset. Thereafter, we invited authors of selected studies to participate in this work by providing IPD from their cohorts. We used standardized individual subject's data to evaluate the association of GFAP concentrations with stroke subtype, demographics, stroke characteristics and factors related with GFAP measurement.From 4 selected studies, we collected data of 340 patients (236 AIS and 104 ICH). Standardized GFAP blood levels were significantly elevated in ICH compared with those with AIS (median and IQR: 0.84 (0.781-1.24), 0.79 (0.74-0.81); p<0.0001). In both stroke types, GFAP concentrations correlated with baseline stroke severity (r=0.27, p<0.0001; r=0.36, p<0.001; for AIS and ICH, respectively) but no correlation was found regarding time to sampling. Limited data precluded the evaluation of GFAP levels and functional outcome.These findings demonstrate substantially different levels of GFAP in the blood of patients with ICH compared with patients with AIS soon after the event, while no association was found with outcome. In summary, GFAP could be a valuable diagnostic tool to assist in medical decision-making and to optimize management of stroke in the acute setting.
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Affiliation(s)
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Emilio Pecharroman
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Georgios Tsivgoulis
- Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Michal Rozanski
- Department of Neurology, Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
| | - Heinrich Audebert
- Department of Neurology, Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
| | - Stefania Mondello
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina, Italy
| | - Victor Llombart
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Joan Montaner
- Neurology, Virgen Macarena University Hospital, Sevilla, Spain .,Neurovascular Laboratory, Vall d'Hebron Hospital, Barcelona, Spain
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21
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Misra S, Montaner J, Ramiro L, Arora R, Talwar P, Nath M, Kumar A, Kumar P, Pandit AK, Mohania D, Prasad K, Vibha D. Blood biomarkers for the diagnosis and differentiation of stroke: A systematic review and meta-analysis. Int J Stroke 2020; 15:704-721. [DOI: 10.1177/1747493020946157] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Correct diagnosis of stroke and its subtypes is pivotal in early stages for optimum treatment. Aims The aim of this systematic review and meta-analysis is to summarize the published evidence on the potential of blood biomarkers in the diagnosis and differentiation of stroke subtypes. Methods A literature search was conducted for papers published until 20 April 2020 in PubMed, EMBASE, Cochrane Library, TRIP, and Google Scholar databases to search for eligible studies investigating the role of blood biomarkers in diagnosing stroke. Quality assessment was done using modified Quality Assessment of Diagnostic Accuracy Studies questionnaire. Pooled standardized mean difference and 95% confidence intervals were calculated. Presence of heterogeneity among the included studies was investigated using the Cochran's Q statistic and I2 metric tests. If I2 was < 50% then a fixed-effect model was applied else a random-effect model was applied. Risk of bias was assessed using funnel plots and between-study heterogeneity was assessed using meta-regression and sensitivity analyses. Entire statistical analysis was conducted in STATA version 13.0. Results A total of 40 studies including patients with 5001 ischemic strokes, 756 intracerebral hemorrhage, 554 stroke mimics, and 1774 healthy control subjects analyzing 25 biomarkers (within 24 h after symptoms onset/after the event) were included in our meta-analysis; 67.5% of studies had moderate evidence of quality. Brain natriuretic peptide, matrix metalloproteinase-9, and D-dimer significantly differentiated ischemic stroke from intracerebral hemorrhage, stroke mimics, and health control subjects ( p < 0.05). Glial fibrillary acidic protein successfully differentiated ischemic stroke from intracerebral hemorrhage (standardized mean difference −1.04; 95% confidence interval −1.46 to −0.63) within 6 h. No studies were found to conduct a meta-analysis of blood biomarkers differentiating transient ischemic attack from healthy controls and stroke mimics. Conclusion This meta-analysis highlights the potential of brain natriuretic peptide, matrix metalloproteinase-9, D-dimer, and glial fibrillary acidic protein as diagnostic biomarkers for stroke within 24 h. Results of our meta-analysis might serve as a platform for conducting further targeted proteomics studies and phase-III clinical trials. PROSPERO Registration ID: CRD42019139659.
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Affiliation(s)
- Shubham Misra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville & Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Laura Ramiro
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rohan Arora
- Zucker Schoool of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Pumanshi Talwar
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Manabesh Nath
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Kumar
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Pradeep Kumar
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Awadh K Pandit
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Dheeraj Mohania
- Dr. R.P. Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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22
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Lumley HA, Flynn D, Shaw L, McClelland G, Ford GA, White PM, Price CI. A scoping review of pre-hospital technology to assist ambulance personnel with patient diagnosis or stratification during the emergency assessment of suspected stroke. BMC Emerg Med 2020; 20:30. [PMID: 32336270 PMCID: PMC7183583 DOI: 10.1186/s12873-020-00323-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/08/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pre-hospital identification of key subgroups within the suspected stroke population could reduce delays to emergency treatment. We aimed to identify and describe technology with existing proof of concept for diagnosis or stratification of patients in the pre-hospital setting. METHODS A systematic electronic search of published literature (from 01/01/2000 to 06/06/2019) was conducted in five bibliographic databases. Two reviewers independently assessed eligibility of studies or study protocols describing diagnostic/stratification tests (portable imaging/biomarkers) or technology facilitating diagnosis/stratification (telemedicine) used by ambulance personnel during the assessment of suspected stroke. Eligible descriptions required use of tests or technology during the actual assessment of suspected stroke to provide information directly to ambulance personnel in the pre-hospital setting. Due to study, intervention and setting heterogeneity there was no attempt at meta-analysis. RESULTS 2887 articles were screened for eligibility, 19 of which were retained. Blood biomarker studies (n = 2) were protocols of prospective diagnostic accuracy studies, one examining purines and the other a panel of known and novel biomarkers for identifying stroke sub-types (versus mimic). No data were yet available on diagnostic accuracy or patient health outcomes. Portable imaging studies (n = 2) reported that an infrared screening device for detecting haemorrhages yielded moderate sensitivity and poor specificity in a small study, whilst a dry-EEG study to detect large vessel occlusion in ischaemic stroke has not yet reported results. Fifteen evaluations of pre-hospital telemedicine were identified (12 observational and 3 controlled comparisons) which all involved transmission of stroke assessment data from the pre-hospital setting to the hospital. Diagnosis was generally comparable with hospital diagnosis and most telemedicine systems reduced time-to-treatment; however, it is unknown whether this time saving translated into more favourable clinical outcomes. Telemedicine systems were deemed acceptable by clinicians. CONCLUSIONS Pre-hospital technologies to identify clinically important subgroups amongst the suspected stroke population are in development but insufficient evidence precludes recommendations about routine use in the pre-hospital setting. Multi-centre diagnostic accuracy studies and clinical utility trials combining promising technologies are warranted.
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Affiliation(s)
- Hannah A Lumley
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health and Social Care, Teesside University, Tees Valley, UK
| | - Lisa Shaw
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Graham McClelland
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, England
| | - Gary A Ford
- Medical Sciences Division, Oxford Academic Health Science Network, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil M White
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, England
| | - Christopher I Price
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, England
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23
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Kamtchum-Tatuene J, Jickling GC. Blood Biomarkers for Stroke Diagnosis and Management. Neuromolecular Med 2019; 21:344-368. [PMID: 30830566 PMCID: PMC6722038 DOI: 10.1007/s12017-019-08530-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/19/2019] [Indexed: 12/20/2022]
Abstract
Biomarkers are objective indicators used to assess normal or pathological processes, evaluate responses to treatment and predict outcomes. Many blood biomarkers already guide decision-making in clinical practice. In stroke, the number of candidate biomarkers is constantly increasing. These biomarkers include proteins, ribonucleic acids, lipids or metabolites. Although biomarkers have the potential to improve the diagnosis and the management of patients with stroke, there is currently no marker that has demonstrated sufficient sensitivity, specificity, rapidity, precision, and cost-effectiveness to be used in the routine management of stroke, thus highlighting the need for additional work. A better standardization of clinical, laboratory and statistical procedures between centers is indispensable to optimize biomarker performance. This review focuses on blood biomarkers that have shown promise for translation into clinical practice and describes some newly reported markers that could add to routine stroke care. Avenues for the discovery of new stroke biomarkers and future research are discussed. The description of the biomarkers is organized according to their expected application in clinical practice: diagnosis, treatment decision, and outcome prediction.
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Affiliation(s)
- Joseph Kamtchum-Tatuene
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, 4-120 Katz Building, 114 Street & 87 Avenue, Edmonton, AB, T6G 2E1, Canada.
| | - Glen C Jickling
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, 4-120 Katz Building, 114 Street & 87 Avenue, Edmonton, AB, T6G 2E1, Canada
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
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24
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Kumar A, Misra S, Yadav AK, Sagar R, Verma B, Grover A, Prasad K. Role of glial fibrillary acidic protein as a biomarker in differentiating intracerebral haemorrhage from ischaemic stroke and stroke mimics: a meta-analysis. Biomarkers 2019; 25:1-8. [DOI: 10.1080/1354750x.2019.1691657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Amit Kumar
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Shubham Misra
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Kumar Yadav
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ram Sagar
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Bhawna Verma
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashoo Grover
- Indian Council for Medical Research, New Delhi, India
| | - Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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25
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Jeffrey J, D'Cunha H, Suzuki M. Blood Level of Glial Fibrillary Acidic Protein (GFAP) Does not Correlate With Disease Progression in a Rat Model of Familial ALS (SOD1 G93A Transgenic). Front Neurol 2018; 9:954. [PMID: 30487774 PMCID: PMC6246740 DOI: 10.3389/fneur.2018.00954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/24/2018] [Indexed: 12/14/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by specific loss of motor neurons in the spinal cord and brain stem. Currently, there are limited options for treating ALS and further investigation of the disease etiology and ALS disease progression need to be completed. There is an urgent need to identify biomarkers to detect and study disease progression in ALS. Glial fibrillary acidic protein (GFAP) is an intermediate filament protein that is expressed by a number of cells related to the central nervous system including glial cells and ependymal cells. Recent studies indicated that significant levels of GFAP protein were detected in peripheral tissues, such as skeletal muscle. In this study, we hypothesized that levels of GFAP in blood represent a biomarker of disease progression in ALS. To test this specific hypothesis, we used a rat model of familial ALS (SOD1G93A transgenic), which has been extensively used to understand the complexity of this devastating disease. Disease progression in a cohort of male and female SOD1G93A transgenic rats was monitored by motor function, and blood samples were collected when these animals reached disease end-stage. We measured GFAP protein levels by ELISA and found no correlation between GFAP concentration and disease progression in either serum and plasma samples of SOD1G93A transgenic. Further investigation would be required in order to implicate blood GFAP as a potential biomarker for ALS.
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Affiliation(s)
- Jeremy Jeffrey
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI, United States
| | - Hannah D'Cunha
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI, United States
| | - Masatoshi Suzuki
- Department of Comparative Biosciences, University of Wisconsin-Madison, Madison, WI, United States.,The Stem Cell and Regenerative Medicine Center, University of Wisconsin-Madison, Madison, WI, United States
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26
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Perry LA, Lucarelli T, Penny-Dimri JC, McInnes MDF, Mondello S, Bustamante A, Montaner J, Foerch C, Kwan P, Davis S, Yan B. Glial fibrillary acidic protein for the early diagnosis of intracerebral hemorrhage: Systematic review and meta-analysis of diagnostic test accuracy. Int J Stroke 2018; 14:390-399. [DOI: 10.1177/1747493018806167] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and aims Glial fibrillary acidic protein (GFAP) has shown promise in several studies for its ability to diagnose intracerebral hemorrhage (ICH). We evaluated the diagnostic accuracy of blood GFAP level to differentiate (ICH) from acute ischemic stroke (AIS) and stroke mimics, both overall, and in the first three hours after symptom onset. Methods We searched multiple databases, without language restriction, from inception until December 2017. Hierarchical summary receiver operating characteristic (HSROC) modeling was used to meta-analyze results. We conducted subgroup analyses restricted to blood samples collected within 0–60, 60–120, and 120–180 min time groups after symptom onset, to evaluate diagnostic accuracy in the early pre-hospital phase. Between and within study heterogeneity was explored using meta-regression. Results The search identified 199 potentially relevant citations from which 11 studies involving 1297 participants (350 ICH, 947 AIS, or mimic) were included. The pooled sensitivity, specificity, and area under the HSROC curve were 0.756 (95% CI 0.630–0.849), 0.945 (95% CI 0.858–0.980), and 0.904 (95% CI 0.878–0.931), respectively. Differences in assays used, but not the other covariates, partially explained between-study heterogeneity ( p = 0.034). The summary estimates for the 0–60, 60–120, and 120–180 min subgroups were comparable to the primary analysis and there was no statistically significant difference in diagnostic accuracy between subgroups. Conclusions GFAP is a promising diagnostic biomarker for ICH diagnosis in the early pre-hospital phase. Test accuracy is affected by assay subtype, but there are still unexplained sources of heterogeneity. High quality, international multi-center trials are warranted to develop and validate a point-of-care GFAP assay for the rapid triage and evaluation of acute stroke in the pre-hospital setting.
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Affiliation(s)
- Luke A Perry
- Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Australia
| | - Tom Lucarelli
- Department of Neuroscience, Eastern Health, Australia
| | | | - Matthew DF McInnes
- Department of Radiology, University of Ottawa, Canada
- Ottawa Hospital Research Institute Clinical Epidemiology Program, Ottawa, Canada
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
- “Oasi” Institute for Research on Mental Retardation and Brain Aging (I.R.C.C.S.), Troina (EN), Italy
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
- Department of Neurology, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
- Department of Neurology, Hospital Universitari Vall d'Hebron. Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Patrick Kwan
- Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Australia
| | - Stephen Davis
- Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Australia
| | - Bernard Yan
- Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Australia
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27
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van Gaal S, Demchuk A. Clinical and Technological Approaches to the Prehospital Diagnosis of Large Vessel Occlusion. Stroke 2018. [PMID: 29540610 DOI: 10.1161/strokeaha.117.017947] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen van Gaal
- From the Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada (S.v.G.); and Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (A.D.).
| | - Andrew Demchuk
- From the Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada (S.v.G.); and Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, Canada (A.D.)
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Liu G, Geng J. Glial fibrillary acidic protein as a prognostic marker of acute ischemic stroke. Hum Exp Toxicol 2018; 37:1048-1053. [PMID: 29308673 DOI: 10.1177/0960327117751236] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background: We investigated the association between serum levels of glial fibrillary acidic protein (GFAP) and stroke functional outcomes in a cohort of 286 patients with acute ischemic stroke (AIS). Methods: We prospectively studied 286 patients with AIS who were admitted within 24 h after the onset of symptoms. Serum levels of GFAP and National Institutes of Health Stroke Scale (NIHSS) were measured at admission. The primary end point was stroke functional outcome among 1-year after stroke onset. We used logistic regression models to assess the relationship between GFAP levels and stroke outcomes. Results: The GFAP level was obtained with a median value of 0.18 (interquartile ranges (IQRs): 0.09–0.28) ng/ml. In multivariable models adjusted for age, gender, and other risk factors, GFAP levels were associated with an increased risk of a NIHSS>6 (odds ratio (OR) = 1.55; 95% confidence interval (CI): 1.16–1.89; p = 0.012). The poor outcome distribution across the GFAP quartiles ranged between 12.7% (first quartile) and 70.4% (fourth quartile). After adjusting for other established risk factors, in multivariate models comparing the Q3 and Q 4 quartiles against the Q1 of the GFAP, the levels of GFAP were associated with poor outcome, and the adjusted risk of poor outcome increased by 211% (3.11[1.80–5.05], p < 0.001) and 522% (6.22[2.98–11.83], p < 0.001), respectively. Interestingly, GFAP improved the ability of NIHSS score to diagnose poor outcomes (area under the curve [AUC] of the combined model 0.82; 95% CI: 0.77–0.88; p = 0.02). Conclusion: GFAP levels are a novel and complementary biomarker to predict functional outcome 1 year after AIS
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Affiliation(s)
- G Liu
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - J Geng
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
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Peacock WF, Van Meter TE, Mirshahi N, Ferber K, Gerwien R, Rao V, Sair HI, Diaz-Arrastia R, Korley FK. Derivation of a Three Biomarker Panel to Improve Diagnosis in Patients with Mild Traumatic Brain Injury. Front Neurol 2017; 8:641. [PMID: 29250027 PMCID: PMC5714862 DOI: 10.3389/fneur.2017.00641] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/15/2017] [Indexed: 12/21/2022] Open
Abstract
Background Nearly 5 million emergency department (ED) visits for head injury occur each year in the United States, of which <10% of patients show abnormal computed tomography (CT) findings. CT negative patients frequently suffer protracted somatic, behavioral, and neurocognitive dysfunction. Our goal was to evaluate biomarkers to identify mild TBI (mTBI) in patients with suspected head injury. Methods An observational ED study of head-injured and control patients was conducted at Johns Hopkins University (HeadSMART). Head CT was obtained (ACEP criteria) in patients with Glasgow Coma Scale scores of 13–15 and aged 18–80. Three candidate biomarker proteins, neurogranin (NRGN), neuron-specific enolase (NSE), and metallothionein 3 (MT3), were evaluated by immunoassay (samples <24 h from injury). American Congress of Rehabilitation Medicine (ACRM) criteria were used for diagnosis of mTBI patients for model building. Univariate analysis, logistic regression, and random forest (RF) algorithms were used for data analysis in R. Overall, 662 patients were studied. Statistical models were built using 328 healthy controls and 179 mTBI patients. Results Median time from injury was 5.9 h (IQR, 4.0; range 0.8–24 h). mTBI patients had elevated NSE, but decreased MT3 versus controls (p < 0.01 for each). NRGN was also elevated but within 2–6 h after injury. In the derivation set, the best model to distinguish mTBI from healthy controls used three markers, age, and sex as covariates (C-statistic = 0.91, sensitivity 98%, specificity 72%). Panel test accuracy was validated with the 155 remaining ACRM+ mTBI patients. Applying the RF model to the ACRM+ mTBI validation set resulted in 78% correctly classified as mTBI (119/153). CT positive and CT negative validation subsets were 91% and 75% correctly classified. In samples taken <2 h from injury, 100% (10/10) samples classified correctly, indicating that hyperacute testing is possible with these biomarker assays. The model accuracy varied from 72–100% overall, and had greater accuracy with increasing severity, as shown by comparing CT+ with CT− (91% versus 75%), and Injury Severity Score ≥16 versus <16 (88% versus 72%, respectively). Objective blood tests, detecting NRGN, NSE, and MT3, can be used to identify mTBI, irrespective of neuroimaging findings.
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Affiliation(s)
- W Frank Peacock
- Department of Emergency Medicine, Ben Taub Hospital, Houston, TX, United States
| | - Timothy E Van Meter
- Program for Neurological Diseases, ImmunArray, Inc., Richmond, VA, United States
| | - Nazanin Mirshahi
- Program for Neurological Diseases, ImmunArray, Inc., Richmond, VA, United States
| | - Kyle Ferber
- Program for Neurological Diseases, ImmunArray, Inc., Richmond, VA, United States
| | - Robert Gerwien
- Gerwien Statistical Consulting, Newington, CT, United States
| | - Vani Rao
- Department of Psychiatry and Behavioral Science, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | - Haris Iqbal Sair
- Department of Radiology, Johns Hopkins University, Baltimore, MD, United States
| | - Ramon Diaz-Arrastia
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, PA, United States
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
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Lindsberg PJ, Kuisma M, Mattila OS. How development of blood biomarkers could benefit prehospital management of acute stroke. Biomark Med 2017; 11:1043-1046. [PMID: 29182027 DOI: 10.2217/bmm-2017-0238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Perttu J Lindsberg
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,Molecular Neurology, Research Programs Unit & Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Markku Kuisma
- Section of Emergency Medical Services, Department of Emergency Medicine, Helsinki University Hospital & University of Helsinki, Finland
| | - Olli S Mattila
- Molecular Neurology, Research Programs Unit & Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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Audebert H, Fassbender K, Hussain MS, Ebinger M, Turc G, Uchino K, Davis S, Alexandrov A, Grotta J. The PRE-hospital Stroke Treatment Organization. Int J Stroke 2017; 12:932-940. [DOI: 10.1177/1747493017729268] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The PRE-hospital Stroke Treatment Organization was formed in 2016 as an international consortium of medical practitioners involved in pre-hospital treatment of patients with acute stroke. Aims PRE-hospital Stroke Treatment Organization’s mission is to improve stroke outcomes by supporting research and advocacy for pre-hospital stroke treatment in Mobile Stroke Units. PRE-hospital Stroke Treatment Organization will provide a platform to enhance collaborative research across the spectrum of acute stroke management in the pre-hospital setting. PRE-hospital Stroke Treatment Organization will also facilitate the appropriate proliferation and distribution of Mobile Stroke Units by providing a forum for professional communication, resource for public education, and stimulus for government, industry, and philanthropic support. Summary of review In this “white paper”, we describe the evidence supporting pre-hospital stroke treatment, progress to date, practical issues such as application in various environments and staffing, planned research initiatives, and organizational structure. Conclusions PRE-hospital Stroke Treatment Organization is not-for-profit, with membership open to anyone involved (or hoping to become involved) in pre-hospital stroke care. PRE-hospital Stroke Treatment Organization has a Steering Committee comprised of members from Europe, U.S., Canada, Australia, and other regions having a Mobile Stroke Unit in operation. PRE-hospital Stroke Treatment Organization convenes satellite meetings for membership at the International Stroke Conference and European Stroke Congress each year to address the PRE-hospital Stroke Treatment Organization mission. The first research collaborations agreed upon are to: (1) develop a list of common data elements to be collected by all Mobile Stroke Unit programs and entered into a common research database, and (2) develop a protocol for investigating the natural history of hyper-acute Intracerebral Hemorrhage.
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Affiliation(s)
- Heinrich Audebert
- Department of Neurology, Charite-Universitaetsmedizin, Berlin, Germany
| | - Klaus Fassbender
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | | | - Martin Ebinger
- Department of Neurology, Charite-Universitaetsmedizin, Berlin, Germany
- Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Guillaume Turc
- Department of Neurology, Charite-Universitaetsmedizin, Berlin, Germany
- Department of Neurology, Hopital Sainte-Anne, Paris, France
| | | | - Stephen Davis
- The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Anne Alexandrov
- College of Nursing and College of Medicine Department of Neurology, University of Tennessee Health Science Center, Memphis, USA
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Katsanos AH, Makris K, Stefani D, Koniari K, Gialouri E, Lelekis M, Chondrogianni M, Zompola C, Dardiotis E, Rizos I, Parissis J, Boutati E, Voumvourakis K, Tsivgoulis G. Plasma Glial Fibrillary Acidic Protein in the Differential Diagnosis of Intracerebral Hemorrhage. Stroke 2017; 48:2586-2588. [PMID: 28751552 DOI: 10.1161/strokeaha.117.018409] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/14/2017] [Accepted: 06/29/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Plasma GFAP (glial fibrillary acidic protein) has recently emerged as a potential biomarker for the differentiation of acute intracerebral hemorrhage (ICH) from acute ischemic stroke (AIS). We prospectively assessed the diagnostic accuracy of GFAP in the differential diagnosis of ICH. METHODS Consecutive patients presenting to the emergency department within 6 hours from symptom onset were evaluated. All patients underwent extensive diagnostic work-up and were classified according to discharge diagnosis in AIS, ICH, subarachnoid hemorrhage, and stroke mimics. GFAP was also measured in healthy volunteers (controls). Baseline stroke severity was evaluated using National Institutes of Health Stroke Scale. Receiver operating characteristic curve analysis was used to identify the optimal cutoff point for the differentiation between subgroups. Correlation analyses of GFAP plasma concentrations with baseline National Institutes of Health Stroke Scale and onset to sampling time were performed with the nonparametric Spearman rank test and fractional polynomial regression, respectively. RESULTS Our study population consisted of 270 individuals (AIS: 121, ICH: 34, stroke mimics: 31, subarachnoid hemorrhage: 5, controls: 79). No differences on baseline stroke severity and onset to sampling time were detected between AIS and ICH. Higher median plasma GFAP values were documented in ICH compared with AIS, stroke mimics, and controls (P<0.001). Receiver operating characteristic analysis highlighted a cutoff value of 0.43 ng/mL as the optimal threshold for the differentiation between ICH and AIS (sensitivity: 91%, specificity: 97%). No association was detected between plasma GFAP concentrations and baseline stroke severity for both AIS (P=0.515) and ICH (P=0.387). In the fractional polynomial analysis, the association between GFAP concentration and onset to sampling time was best described by a J-shaped curve for AIS and an inverted U-shaped curve for ICH, with a peak at 2 hours. CONCLUSIONS Plasma GFAP seems to be a sensitive and specific biomarker for the differentiation of ICH from both AIS and other acute neurological disorders, with the optimal diagnostic yield being present in the second hour from symptom onset.
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Affiliation(s)
- Aristeidis H Katsanos
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Konstantinos Makris
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Dimitra Stefani
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Katerina Koniari
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Eleni Gialouri
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Moses Lelekis
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Maria Chondrogianni
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Christina Zompola
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Efthymios Dardiotis
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Ioannis Rizos
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - John Parissis
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Eleni Boutati
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Konstantinos Voumvourakis
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.)
| | - Georgios Tsivgoulis
- From the Second Department of Neurology (A.H.K., M.C., C.Z., K.V., G.T.), Second Department of Cardiology (I.R., J.P.), and Second Department of Internal Medicine (E.B.), Attikon University Hospital, National and Kapodistrian University of Athens, Greece; Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.); Clinical Biochemistry Department (K.M.) and Department of Internal Medicine (D.S., K.K., E.G., M.L.), KAT General Hospital, Athens, Greece; Department of Neurology, University Hospital of Larissa, Greece (E.D.); and Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.).
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Willis CM, Ménoret A, Jellison ER, Nicaise AM, Vella AT, Crocker SJ. A Refined Bead-Free Method to Identify Astrocytic Exosomes in Primary Glial Cultures and Blood Plasma. Front Neurosci 2017; 11:335. [PMID: 28663721 PMCID: PMC5471332 DOI: 10.3389/fnins.2017.00335] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/29/2017] [Indexed: 01/05/2023] Open
Abstract
Astrocytes are the most abundant glial cell type in the central nervous system (CNS) and are known to fulfill critical homeostatic functions. Dysfunction of activated astrocytes is also known to participate in the development of several neurological diseases. Astrocytes can be uniquely identified by expression of the intermediate filament protein glial acidic fibrillary protein (GFAP). Herein, we report on the development of a rigorous and sensitive methodology to identify GFAP+ exosomes in primary culture using flow cytometry. We then demonstrate that activated astrocytes release increased amounts of exosomes in response to treatment with interleukin-1β. Using this methodology, we report the identification of GFAP+ exosomes in blood and then use a mouse model of inflammatory demyelination, experimental autoimmune encephalomyelitis (EAE), to examine whether the abundance of GFAP+ exosomes in blood circulation changes during clinical illness. We find a detectable increase in the presence of GFAP+ exosomes in EAE mice when compared with non-EAE, control mice. Our data provide a novel perspective on the presence of GFAP in blood as it identifies exosomes as potential astrocyte-derived signals within blood. These data are complementary to previous clinical studies that reported elevated GFAP protein in blood samples from multiple sclerosis (MS) patients during a clinical relapse. These data also reveal the existence of a potential systemic role for astrocyte-derived exosomes in CNS conditions involving inflammation such as multiple sclerosis.
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Affiliation(s)
- Cory M Willis
- Departments of Neuroscience, University of Connecticut School of MedicineFarmington, CT, United States
| | - Antoine Ménoret
- Departments of Immunology, University of Connecticut School of MedicineFarmington, CT, United States
| | - Evan R Jellison
- Departments of Immunology, University of Connecticut School of MedicineFarmington, CT, United States
| | - Alexandra M Nicaise
- Departments of Neuroscience, University of Connecticut School of MedicineFarmington, CT, United States
| | - Anthony T Vella
- Departments of Immunology, University of Connecticut School of MedicineFarmington, CT, United States
| | - Stephen J Crocker
- Departments of Neuroscience, University of Connecticut School of MedicineFarmington, CT, United States
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