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Lin V, Tian C, Wahlster S, Castillo-Pinto C, Mainali S, Johnson NJ. Temperature Control in Acute Brain Injury: An Update. Semin Neurol 2024. [PMID: 38593854 DOI: 10.1055/s-0044-1785647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.
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Affiliation(s)
- Victor Lin
- Department of Neurology, University of Washington, Seattle, Washington
| | - Cindy Tian
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, Washington
- Department of Neurosurgery, University of Washington, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Yang S, Xu D, Zhang D, Huang X, Li S, Wang Y, Lu J, Wang D, Guo ZN, Yang Y, Ye D, Wang Y, Xu A, Hoo RLC, Chang J. Levofloxacin alleviates blood-brain barrier disruption following cerebral ischemia and reperfusion via directly inhibiting A-FABP. Eur J Pharmacol 2024; 963:176275. [PMID: 38113968 DOI: 10.1016/j.ejphar.2023.176275] [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: 08/04/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023]
Abstract
Reperfusion therapy is currently the most effective treatment for acute ischemic stroke, but often results in secondary brain injury. Adipocyte fatty acid-binding protein (A-FABP, FABP4, or aP2) was shown to critically mediate cerebral ischemia/reperfusion (I/R) injury by exacerbating blood-brain barrier (BBB) disruption. However, no A-FABP inhibitors have been approved for clinical use due to safety issues. Here, we identified the therapeutic effect of levofloxacin, a widely used antibiotic displaying A-FABP inhibitory activity in vitro, on cerebral I/R injury and determined its target specificity and action mechanism in vivo. Using molecular docking and site-directed mutagenesis, we showed that levofloxacin inhibited A-FABP activity through interacting with the amino acid residue Asp76, Gln95, Arg126 of A-FABP. Accordingly, levofloxacin significantly inhibited A-FABP-induced JNK phosphorylation and expressions of proinflammatory factors and matrix metalloproteinase 9 (MMP-9) in mouse primary macrophages. In wild-type mice with transient middle cerebral artery occlusion, levofloxacin substantially mitigated BBB disruption and neuroinflammation, leading to reduced cerebral infarction, alleviated neurological outcomes, and improved survival. Mechanistically, levofloxacin decreased MMP-9 expression and activity, and thus reduced degradation of extracellular matrix and endothelial tight junction proteins. Importantly, the BBB- and neuro-protective effects of levofloxacin were abolished in A-FABP or MMP-9 knockout mice, suggesting that the therapeutic effects of levofloxacin highly depended on specific targeting of the A-FABP-MMP-9 axis. Overall, our study demonstrates that levofloxacin alleviates A-FABP-induced BBB disruption and neural tissue injury following cerebral I/R, and unveils its therapeutic potential for the treatment of ischemic stroke.
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Affiliation(s)
- Shilun Yang
- Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Dingkang Xu
- Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China; Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China; Graduate School of Peking Union Medical College, Beijing, China
| | - Dianhui Zhang
- Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China; Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xiaowen Huang
- Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China; Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong; State Key Laboratory of Pharmacological Biotechnology, Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Simeng Li
- Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Yan Wang
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang, 110122, Liaoning, China
| | - Jing Lu
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China
| | - Daming Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China; Graduate School of Peking Union Medical College, Beijing, China
| | - Zhen-Ni Guo
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yi Yang
- Stroke Center, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Dewei Ye
- Key Laboratory of Metabolic Phenotyping in Model Animals, Guangdong Pharmaceutical University, Guangzhou, China
| | - Yu Wang
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong; State Key Laboratory of Pharmacological Biotechnology, Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Aimin Xu
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong; State Key Laboratory of Pharmacological Biotechnology, Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Ruby Lai Chong Hoo
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong; State Key Laboratory of Pharmacological Biotechnology, Faculty of Medicine, The University of Hong Kong, Hong Kong.
| | - Junlei Chang
- Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.
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Diaz-Marugan L, Kantsjö JB, Rutsch A, Ronchi F. Microbiota, diet, and the gut-brain axis in multiple sclerosis and stroke. Eur J Immunol 2023; 53:e2250229. [PMID: 37470461 DOI: 10.1002/eji.202250229] [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: 02/04/2023] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 07/21/2023]
Abstract
Intestinal microbiota can influence the phenotype and function of immune cell responses through the dissemination of bacterial antigens or metabolites. Diet is one of the major forces shaping the microbiota composition and metabolism, contributing to host homeostasis and disease susceptibility. Currently, nutrition is a complementary and alternative approach to the management of metabolic and neurological diseases and cancer. However, the knowledge of the exact mechanism of action of diet and microbiota on the gut-brain communication is only developing in recent years. Here, we reviewed the current knowledge on the effect of diet and microbiota on the gut-brain axis in patients with two different central nervous system diseases, multiple sclerosis and stroke. We have also highlighted the open questions in the field that we believe are important to address to gain a deeper understanding of the mechanisms by which diet can directly or indirectly affect the host via the microbiota. We think this will open up new approaches to the treatment, diagnosis, and monitoring of various diseases.
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Affiliation(s)
- Laura Diaz-Marugan
- Charité - Universitaetsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH): Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Berlin, Germany
- Departamento de Medicina, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Johan B Kantsjö
- Charité - Universitaetsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH): Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Berlin, Germany
| | - Andrina Rutsch
- Charité - Universitaetsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH): Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Berlin, Germany
| | - Francesca Ronchi
- Charité - Universitaetsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH): Institute of Microbiology, Infectious Diseases and Immunology (I-MIDI), Berlin, Germany
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Farag E, Machado S, Argalious M. Multiorgan talks in the presence of brain injury. Curr Opin Anaesthesiol 2023; 36:476-484. [PMID: 37552078 DOI: 10.1097/aco.0000000000001292] [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: 08/09/2023]
Abstract
PURPOSE OF REVIEW The brain is the command center of the rest of the body organs. The normal multiorgan talks between the brain and the rest of the body organs are essential for the normal body homeostasis. In the presence of brain injury, the disturbed talks between the brain and the rest of body organs will result in several pathological conditions. The aim of this review is to present the most recent findings for the pathological conditions that would result from the impaired multiorgan talks in the presence of brain injury. RECENT FINDINGS The brain injury such as in acute ischemic stroke, subarachnoid hemorrhage and traumatic brain injury will result in cascade of pathological talks between the brain and the rest of body organs. These pathological talks could result in pathological conditions such as cardiomyopathy, acute lung and kidney injuries, impaired liver functions, and impaired gut barrier permeability as well. SUMMARY Better understanding of the pathological conditions that could result from the impaired multiorgan talks in the presence of brain injury will open the doors for precise targeted therapies in the future for myriad of pathological conditions.
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Affiliation(s)
- Ehab Farag
- Department of General Anesthesiology, Anesthesia Institute, Cleveland Clinic, Ohio, USA
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Wang Y, Guo J, Yang F, Dong R, Song D, Huang P, Wen L, Xiang G, Wang S, Teng J, Miao W. Predictive effect of the decline in CD4 + T cell levels in blood on infection in patients with severe hemorrhagic stroke and mechanism. Front Neurol 2023; 14:1118282. [PMID: 37360336 PMCID: PMC10288285 DOI: 10.3389/fneur.2023.1118282] [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: 01/16/2023] [Accepted: 05/03/2023] [Indexed: 06/28/2023] Open
Abstract
Objective The purpose of this research was to evaluate the influence of immunity on infection in patients with severe hemorrhagic stroke and explore the mechanism underlying this connection. Methods Clinical data obtained from 126 patients with severe hemorrhagic stroke were retrospectively analyzed, and the factors affecting infection were screened by multivariable logistic regression models. Nomograms, calibration curves, the Hosmer-Lemeshow goodness-of-fit test, and decision curve analysis were used to examine the effectiveness of the models in evaluating infection. The mechanism underlying the reduction in CD4+ T-cell levels in blood was explored by analysis of lymphocyte subsets and cytokines in cerebrospinal fluid (CSF) and blood. Results The results showed that CD4+ T-cell levels of <300/μL was an independent risk factor for early infection. The models for multivariable logistic regression involving the CD4+ T-cell levels and other influencing factors had good applicability and effectiveness in evaluating early infection. CD4+ T-cell levels decreased in blood but increased in CSF. Similarly, interleukin (IL)-6 and IL-8 levels in CSF had a significant increase, generating a substantial concentration gradient between the CSF and the blood. Conclusion Reduced blood CD4+ T-cell counts among patients who had severe hemorrhagic stroke increased the risk of early infection. CSF IL-6 and IL-8 may be involved in inducing the migration of CD4+ T cells into the CSF and decreasing blood CD4+ T-cell levels.
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Affiliation(s)
- Yating Wang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Junshuang Guo
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Department of Immunology, School of Basic Medical Science, Central South University, Changsha, Hunan, China
| | - Fan Yang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ruirui Dong
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Dandan Song
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Peipei Huang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lijun Wen
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Guoliang Xiang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Shuiyu Wang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Junfang Teng
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wang Miao
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Han S, Cai L, Chen P, Kuang W. A study of the correlation between stroke and gut microbiota over the last 20years: a bibliometric analysis. Front Microbiol 2023; 14:1191758. [PMID: 37350780 PMCID: PMC10282156 DOI: 10.3389/fmicb.2023.1191758] [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: 03/22/2023] [Accepted: 05/19/2023] [Indexed: 06/24/2023] Open
Abstract
Purpose This study intends to uncover a more thorough knowledge structure, research hotspots, and future trends in the field by presenting an overview of the relationship between stroke and gut microbiota in the past two decades. Method Studies on stroke and gut microbiota correlations published between 1st January 2002 and 31st December 2021 were retrieved from the Web of Science Core Collection and then visualized and scientometrically analyzed using CiteSpace V. Results A total of 660 papers were included in the study, among which the United States, the United Kingdom, and Germany were the leading research centers. Cleveland Clinic, Southern Medical University, and Chinese Academy of Science were the top three institutions. The NATURE was the most frequently co-cited journal. STANLEY L HAZEN was the most published author, and Tang WHW was the most cited one. The co-occurrence analysis revealed eight clusters (i.e., brain-gut microbiota axis, fecal microbiome transplantation, gut microbiota, hypertension, TMAO, ischemic stroke, neuroinflammation, atopobiosis). "gut microbiota," "Escherichia coli," "cardiovascular disease," "risk," "disease," "ischemic stroke," "stroke," "metabolism," "inflammation," and "phosphatidylcholine" were the most recent keyword explosions. Conclusion Findings suggest that in the next 10 years, the number of publications produced annually may increase significantly. Future research trends tend to concentrate on the mechanisms of stroke and gut microbiota, with the inflammation and immunological mechanisms, TMAO, and fecal transplantation as hotspots. And the relationship between these mechanisms and a particular cardiovascular illness may also be a future research trend.
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Affiliation(s)
- Shengnan Han
- Clinical Medical College of Acupuncture, Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Longhui Cai
- First School of Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Peipei Chen
- School of Medical Technology, Qiqihar Medical College, Qiqihar, Heilongjiang, China
| | - Weihong Kuang
- Guangdong Key Laboratory for Research and Development of Natural Drugs, School of Pharmacy, Guangdong Medical University, Dongguan, China
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7
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Wang Q, Wu ZY, Tang HL, Yi ZM, Zhai SD. The efficacy and safety of prophylactic antibiotics for post-acute stroke infection: A systematic review and meta-analysis. Br J Clin Pharmacol 2023; 89:946-955. [PMID: 36527261 DOI: 10.1111/bcp.15646] [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: 10/09/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
AIMS Infections are common complications after stroke and associated with unfavourable outcomes. We aimed to evaluate the efficacy and safety of prophylactic antibiotics for post-acute stroke infection. METHODS We searched PubMed, Embase, the Cochrane Library, SinoMed, China National Knowledge Infrastructure, WanFang Data, China Science and Technology Journal Database, and clinical trial register platforms from inception to 15 February 2022. We included randomized clinical trials that evaluated the efficacy and safety of prophylactic antibiotics. Primary outcomes were mortality rate and incidence of pneumonia. The pooled risk ratio (RR) and mean differences with 95% confidence interval (CI) were calculated using the random or fixed-effect model depending on heterogeneity. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations. RESULTS Twelve studies (4809 participants) were included. There was no significant difference in the mortality rate (12 trials, n = 4740, RR 1.03 [95% Cl: 0.91-1.16], high-quality evidence), incidence of pneumonia (7 trials, n = 4352, RR 0.94 [95% CI: 0.79-1.11], high-quality evidence) and the incidence of adverse events between the prophylactic antibiotics and control groups. Prophylactic antibiotics significantly reduced the incidence of infections (8 trials, n = 4517, RR 0.72 [95% CI: 0.58-0.89], moderate-quality evidence) and urinary tract infections (7 trials, n = 4352, RR 0.39 [95% CI: 0.3-0.49], moderate-quality evidence). None of the subgroup analyses showed a significant difference in mortality or the incidence of pneumonia. CONCLUSION For acute stroke patients, prophylactic antibiotics were significantly associated with fewer incidences of any infections and urinary tract infections without significant differences in mortality rate and pneumonia.
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Affiliation(s)
- Qing Wang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Pharmacy, The First People's Hospital of Yinchuan, Yinchuan, China
| | - Zi-Yang Wu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Hui-Lin Tang
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Zhan-Miao Yi
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Suo-Di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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Preventive ceftriaxone in patients at high risk of stroke-associated pneumonia. A post-hoc analysis of the PASS trial. PLoS One 2022; 17:e0279700. [PMID: 36584124 PMCID: PMC9803205 DOI: 10.1371/journal.pone.0279700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 12/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Infections complicate the acute phase of stroke in one third of patients and especially pneumonia is associated with increased risk of death or dependency. In randomized trials of stroke patients, preventive antibiotics reduced overall infections, but did not reduce pneumonia or improve outcome. This may be explained by broad selection criteria, including many patients with a low risk of pneumonia. To assess the potential of selection of patients at high risk of pneumonia, we performed a post-hoc analysis in the Preventive Antibiotics in Stroke Study (PASS). METHODS PASS was a multicentre phase 3 trial in acute stroke patients who were randomized to preventive ceftriaxone for four days within 24 hours or standard care. For this analysis patients were divided based on the ISAN risk score for pneumonia as follows: low (0-6), medium (7-14) and high (15-21). Primary outcomes were pneumonia rate during admission as judged by the treating physician, and by an independent committee; secondary outcomes were overall infections and unfavorable outcome (modified Rankin Scale ≥3). We adjusted with multivariable regression for possible confounders: age, stroke subtype and severity, pre-stroke dependency and diabetes. RESULTS Pneumonia occurred more frequently in higher risk groups (25.7% (high), 9.0% (medium) 1.5%, (low)). The absolute difference in pneumonia rate between patients treated with ceftriaxone or standard care increased with the ISAN score (low: 0.5%, medium: 1.2%, high: 10.1%). After adjustment ceftriaxone reduced overall infections in the low and medium groups, not in the high-risk group. There was a trend towards reduction of pneumonia as judged by the committee (3.7% vs 13.6%, aOR = 0.164, p = 0.063) in the high-risk group. CONCLUSIONS This post-hoc analysis of PASS confirmed higher rates of pneumonia with higher ISAN scores, and suggests that in acute stroke patients with an ISAN score of ≥15, preventive ceftriaxone for four days may reduce pneumonia rate.
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Wu F, Liu Z, Zhou L, Ye D, Zhu Y, Huang K, Weng Y, Xiong X, Zhan R, Shen J. Systemic immune responses after ischemic stroke: From the center to the periphery. Front Immunol 2022; 13:911661. [PMID: 36211352 PMCID: PMC9533176 DOI: 10.3389/fimmu.2022.911661] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/18/2022] [Indexed: 12/01/2022] Open
Abstract
Ischemic stroke is a leading cause of disability and death. It imposes a heavy economic burden on individuals, families and society. The mortality rate of ischemic stroke has decreased with the help of thrombolytic drug therapy and intravascular intervention. However, the nerve damage caused by ischemia-reperfusion is long-lasting and followed by multiple organ dysfunction. In this process, the immune responses manifested by systemic inflammatory responses play an important role. It begins with neuroinflammation following ischemic stroke. The large number of inflammatory cells released after activation of immune cells in the lesion area, along with the deactivated neuroendocrine and autonomic nervous systems, link the center with the periphery. With the activation of systemic immunity and the emergence of immunosuppression, peripheral organs become the second “battlefield” of the immune response after ischemic stroke and gradually become dysfunctional and lead to an adverse prognosis. The purpose of this review was to describe the systemic immune responses after ischemic stroke. We hope to provide new ideas for future research and clinical treatments to improve patient outcomes and quality of life.
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Affiliation(s)
- Fan Wu
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zongchi Liu
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lihui Zhou
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Di Ye
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Zhu
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Kaiyuan Huang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuxiang Weng
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoxing Xiong
- Department of Clinical Laboratory, Renmin Hospital, Faculty of Medical Sciences, Wuhan University, Wuhan, China
| | - Renya Zhan
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Jian Shen, ; Renya Zhan,
| | - Jian Shen
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Jian Shen, ; Renya Zhan,
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McCulloch L, Mouat IC, South K, McColl BW, Allan SM, Smith CJ. Stroke-induced changes to immune function and their relevance to increased risk of severe COVID-19 disease. DISCOVERY IMMUNOLOGY 2022; 1:kyac004. [PMID: 38566903 PMCID: PMC10917238 DOI: 10.1093/discim/kyac004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/07/2022] [Accepted: 08/01/2022] [Indexed: 04/04/2024]
Abstract
As the COVID-19 pandemic moves towards endemic disease, it remains of key importance to identify groups of individuals vulnerable to severe infection and understand the biological factors that mediate this risk. Stroke patients are at increased risk of developing severe COVID-19, likely due to stroke-induced alterations to systemic immune function. Furthermore, immune responses associated with severe COVID-19 in patients without a history of stroke parallel many of the immune alterations induced by stroke, possibly resulting in a compounding effect that contributes to worsened disease severity. In this review, we discuss the changes to systemic immune function that likely contribute to augmented COVID-19 severity in patients with a history of stroke and the effects of COVID-19 on the immune system that may exacerbate these effects.
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Affiliation(s)
- Laura McCulloch
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Isobel C Mouat
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Kieron South
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Barry W McColl
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Stuart M Allan
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Craig J Smith
- Lydia Becker Institute of Immunology and Inflammation, Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, University of Manchester, Manchester, UK
- Greater Manchester Comprehensive Stroke Centre, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
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11
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Westendorp WF, Vermeij JD, Smith CJ, Kishore AK, Hodsoll J, Kalra L, Meisel A, Chamorro A, Chang JJ, Rezaei Y, Amiri-Nikpour MR, DeFalco FA, Switzer JA, Blacker DJ, Dijkgraaf MG, Nederkoorn PJ, van de Beek D. Preventive antibiotic therapy in acute stroke patients: A systematic review and meta-analysis of individual patient data of randomized controlled trials. Eur Stroke J 2022; 6:385-394. [PMID: 35342808 PMCID: PMC8948510 DOI: 10.1177/23969873211056445] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction Infection after stroke is associated with unfavorable outcome. Randomized
controlled studies did not show benefit of preventive antibiotics in stroke
but lacked power for subgroup analyses. Aim of this study is to assess
whether preventive antibiotic therapy after stroke improves functional
outcome for specific patient groups in an individual patient data
meta-analysis. Patients and methods We searched MEDLINE (1946–7 May 2021), Embase (1947–7 May 2021), CENTRAL
(17th September 2021), trial registries, cross-checked references and
contacted researchers for randomized controlled trials of preventive
antibiotic therapy versus placebo or standard care in ischemic or
hemorrhagic stroke patients. Meta-analysis was performed by a one-step and
two-step approach. Primary outcome was functional outcome adjusted for age
and stroke severity. Secondary outcomes were infections and mortality. Results 4197 patients from nine trials were included. Preventive antibiotic therapy
was not associated with a shift in functional outcome (mRS) at 3 months
(OR1.13, 95%CI 0.98–1.31) or unfavorable functional outcome (mRS 3–6)
(OR0.85, 95%CI 0.60–1.19). Preventive antibiotics did not improve functional
outcome in pre-defined subgroups (age, stroke severity, timing and type of
antibiotic therapy, pneumonia prediction scores, dysphagia, type of stroke,
and type of trial). Preventive antibiotics reduced infections (276/2066
(13.4%) in the preventive antibiotic group vs. 417/2059 (20.3%) in the
control group, OR 0.60, 95% CI 0.51–0.71, p < 0.001),
but not pneumonia (191/2066 (9.2%) in the preventive antibiotic group vs.
205/2061 (9.9%) in the control group (OR 0.92 (0.75–1.14),
p = 0.450). Discussion and conclusion Preventive antibiotic therapy did not benefit any subgroup of patients with
acute stroke and currently cannot be recommended.
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Affiliation(s)
- Willeke F Westendorp
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jan-Dirk Vermeij
- Department of Neurology, Sint Franciscusziekenhuis, Heusden-Zolder, Belgium
| | - Craig J Smith
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Amit K Kishore
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - John Hodsoll
- Biostatistics Department, NIHR Biomedical Research Centre for Mental Health and Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
| | - Lalit Kalra
- Clinical Neurosciences, King's College Hospital NHS Foundation Trust, London, UK
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Berlin, Germany
| | - Angel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran; Department of Cardiology, Seyyed-al-Shohada Heart Center, Urmia University of Medical Science, West Azerbaijan, Iran
| | | | | | - Jeffrey A Switzer
- Department of Neurology, Medical College of Georgia, Augusta, ME, USA
| | - David J Blacker
- Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia; Department of Neurology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; School of Medicine and Pharmacology, University of Western Australia
| | - Marcel Gw Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Center, Amsterdam, The Netherlands
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12
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Dziewas R, Michou E, Trapl-Grundschober M, Lal A, Arsava EM, Bath PM, Clavé P, Glahn J, Hamdy S, Pownall S, Schindler A, Walshe M, Wirth R, Wright D, Verin E. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J 2021; 6:LXXXIX-CXV. [PMID: 34746431 DOI: 10.1177/23969873211039721] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/27/2021] [Indexed: 12/30/2022] Open
Abstract
Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.
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Affiliation(s)
- Rainer Dziewas
- Department of Neurology, University Hospital Münster, Münster, Germany.,Department of Neurology and Neurorehabilitation, Klinikum Osnabrück, Osnabrück, Germany
| | - Emilia Michou
- Department of Speech Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Greece.,Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | | | - Avtar Lal
- Guidelines Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Ethem Murat Arsava
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Pere Clavé
- Centro de Investigación Biomédica en Red de Enfermedades, Hepáticas y Digestivas (CIBERehd), Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Hospital Ruhr-University Bochum, Germany
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Sue Pownall
- Department of Speech & Language Therapy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences, Phoniatric Unit, Sacco Hospital Milano, University of Milano, Milan, Italy
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College, Dublin, Ireland
| | - Rainer Wirth
- Department of Geriatric Medicine, Marien Hospital Herne, University Hospital Ruhr-University Bochum, Germany
| | - David Wright
- School of Pharmacy, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Eric Verin
- Department of Physical and Rehabilitation Medicine, Rouen University Hospital, Rouen, France
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13
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Ndakotsu A, Myneni R, Iqbal A, Grewal AS, Abubacker AP, Vivekanandan G, Chawla HV, Khan S. Prophylactic Antibiotics, the Mediator of Post-Stroke Infections: A Systematic Review. Cureus 2021; 13:e15055. [PMID: 34150402 PMCID: PMC8208172 DOI: 10.7759/cureus.15055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Infections frequently complicate an acute stroke and have been associated with an unfavorable prognosis among patients. The use of prophylactic antibiotics seems rational, however, its efficacy has remained obscure. This systematic review aims to offer more clarity to this established dilemma. PubMed and Google Scholar were explored to gain access to studies on post-stroke infection. A systematic review was carried out to analyze how profitable it would be to offer preventive antibiotics immediately after an acute stroke. Five randomized control trials were obtained and analyzed the efficacy of antibiotics in acute stroke according to their intrinsic effects on the infection rate, functionality, and mortality benefits. Based on our findings, we discovered that antibiotics reduce the onset of early infections, especially urinary tract infections, but have absolutely no effect on the functionality and offer no mortality benefit. These results were emphatically shown in two large, open-labeled randomized controlled trials involved in this systematic review. Prophylactic antibiotics provide no additional benefits to the standard of care and should not be used following an acute stroke. They may decrease the incidence of acute infections, especially urinary tract infections, but have no effects on functional outcome and mortality.
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Affiliation(s)
- Andrew Ndakotsu
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Revathi Myneni
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aimen Iqbal
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Amit S Grewal
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ansha P Abubacker
- Emergency Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Govinathan Vivekanandan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Harsh V Chawla
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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14
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Abstract
Patients with stroke have a high risk of infection which may be predicted by age, procalcitonin, interleukin-6, C-reactive protein, National Institute of Health stroke scale (NHSS) score, diabetes, etc. These prediction methods can reduce unfavourable outcome by preventing the occurrence of infection.We aim to identify early predictors for urinary tract infection in patients after stroke.In 186 collected acute stroke patients, we divided them into urinary tract infection group, other infection type groups, and non-infected group. Data were recorded at admission. Independent risk factors and infection prediction model were determined using Logistic regression analyses. Likelihood ratio test was used to detect the prediction effect of the model. Receiver operating characteristic curve and the corresponding area under the curve were used to measure the predictive accuracy of indicators for urinary tract infection.Of the 186 subjects, there were 35 cases of urinary tract infection. Elevated interleukin-6, higher NIHSS, and decreased hemoglobin may be used to predict urinary tract infection. And the predictive model for urinary tract infection (including sex, NIHSS, interleukin-6, and hemoglobin) have the best predictive effect.This study is the first to discover that decreased hemoglobin at admission may predict urinary tract infection. The prediction model shows the best accuracy.
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Affiliation(s)
- Ya-ming Li
- Department of Neurology, Jiading District Central Hospital affiliated to Shanghai University of Medicine & Health Sciences
| | - Jian-hua Xu
- Department of Neurology, Jiading District Central Hospital affiliated to Shanghai University of Medicine & Health Sciences
| | - Yan-xin Zhao
- Department of Neurology, Tenth People's Hospital affiliated to Tongji University, Shanghai, China
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15
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Semerano A, Strambo D, Martino G, Comi G, Filippi M, Roveri L, Bacigaluppi M. Leukocyte Counts and Ratios Are Predictive of Stroke Outcome and Hemorrhagic Complications Independently of Infections. Front Neurol 2020; 11:201. [PMID: 32308640 PMCID: PMC7145963 DOI: 10.3389/fneur.2020.00201] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/06/2020] [Indexed: 01/14/2023] Open
Abstract
Background: Ischemic stroke patients show alterations in peripheral leukocyte counts that may result from the sterile inflammation response as well as the occurrence of early infections. We here aimed to determine whether alterations of circulating leukocytes in acute ischemic stroke are associated with long-term functional outcome and hemorrhagic complications, independently of the occurrence of infections. Methods: Blood laboratory values of patients with acute ischemic stroke, presenting within 4.5 h from symptom onset, were collected. Leukocyte subsets were analyzed in relation to 3-month functional outcome, mortality, and parenchymal hemorrhagic transformation (PH). A multivariable logistic regression analysis, considering the occurrence of early post-stroke infections, was performed for each outcome measure. Results: Five-hundred-ten patients were included in the study. Independently of infections, good functional outcome was associated with a lower neutrophil to lymphocyte ratio (NL-R, OR 0.906 [95% CI 0.822-0.998]), a higher lymphocyte count (OR 1.547 [95% CI 1.051-2.277]), a higher eosinophil count (OR 1.027 [95% CI 1.007-1.048]), and a higher eosinophil to leukocyte ratio (EoLeu-R, OR 1.240 [95% CI 1.071-1.436]) at admission. Death within 3 months was associated with higher NL-R (OR 1.103 [95% CI 1.032-1.179]) as well as with lower eosinophil counts (OR 0.909 [95% CI 0.827-0.999]). Patients developing parenchymal hemorrhagic transformation had higher neutrophil counts (OR 1.420 [95% CI 1.197-1.684]) as well as a higher NL-R (OR 1.192 [95% IC 1.088-1.305]). Conclusion: Leukocyte subtype profiles in the acute phase of ischemic stroke represent a predictor of outcome independently of infections. Stroke-evoked sterile inflammation is a pathophysiological relevant mechanism that deserves further investigation.
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Affiliation(s)
- Aurora Semerano
- Neuroimmunology Unit, Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Hospital, Milan, Italy.,Neurology Department, San Raffaele Hospital, Milan, Italy
| | - Davide Strambo
- Neurology Department, San Raffaele Hospital, Milan, Italy.,Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Gianvito Martino
- Neuroimmunology Unit, Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Hospital, Milan, Italy
| | - Giancarlo Comi
- Neuroimmunology Unit, Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Hospital, Milan, Italy.,Neurology Department, San Raffaele Hospital, Milan, Italy
| | | | - Luisa Roveri
- Neurology Department, San Raffaele Hospital, Milan, Italy
| | - Marco Bacigaluppi
- Neuroimmunology Unit, Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Hospital, Milan, Italy.,Neurology Department, San Raffaele Hospital, Milan, Italy
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16
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Zera KA, Buckwalter MS. The Local and Peripheral Immune Responses to Stroke: Implications for Therapeutic Development. Neurotherapeutics 2020; 17:414-435. [PMID: 32193840 PMCID: PMC7283378 DOI: 10.1007/s13311-020-00844-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The immune response to stroke is an exciting target for future stroke therapies. Stroke is a leading cause of morbidity and mortality worldwide, and clot removal (mechanical or pharmacological) to achieve tissue reperfusion is the only therapy currently approved for patient use. Due to a short therapeutic window and incomplete effectiveness, however, many patients are left with infarcted tissue that stimulates inflammation. Although this is critical to promote repair, it can also damage surrounding healthy brain tissue. In addition, acute immunodepression and subsequent infections are common and are associated with worse patient outcomes. Thus, the acute immune response is a major focus of researchers attempting to identify ways to amplify its benefits and suppress its negative effects to improve short-term recovery of patients. Here we review what is known about this powerful process. This includes the role of brain resident cells such as microglia, peripherally activated cells such as macrophages and neutrophils, and activated endothelium. The role of systemic immune activation and subsequent immunodepression in the days after stroke is also discussed, as is the chronic immune responses and its effects on cognitive function. The biphasic role of inflammation, as well as complex timelines of cell production, differentiation, and trafficking, suggests that the relationship between the acute and chronic phases of stroke recovery is complex. Gaining a more complete understanding of this intricate process by which inflammation is initiated, propagated, and terminated may potentially lead to therapeutics that can treat a larger population of stroke patients than what is currently available. The immune response plays a critical role in patient recovery in both the acute and chronic phases after stroke. In patients, the immune response can be beneficial by promoting repair and recovery, and also detrimental by propagating a pro-inflammatory microenvironment. Thus, it is critical to understand the mechanisms of immune activation following stroke in order to successfully design therapeutics.
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Affiliation(s)
- Kristy A Zera
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA.
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA.
- Department of Neurosurgery, Stanford Univeristy School of Medicine, Stanford, CA, USA.
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17
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Rashid MH, Kabir A, Waris MU, Salman U, Zain S. Role of Prophylactic Antibiotics in Critical Care of Stroke Patients - A Preventive Approach to Post-stroke Infections? Cureus 2020; 12:e7158. [PMID: 32257701 PMCID: PMC7108674 DOI: 10.7759/cureus.7158] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Post-stroke complications are very common worldwide and the most common complication is infection. This contributes the most to the mortality rate in stroke patients. Among the infections, pneumonia and urinary tract infections are most common. Hyperthermia following stroke is associated with neuronal damage and worse outcomes. Post-stroke immunosuppression and activation of inflammatory mediators also cause infections. Based on the high mortality caused by post-stroke infections, various trials were done to seek the advantage that prophylactic antibiotics can give in the critical care of stroke patients. Antibiotics, including ceftriaxone (cephalosporin), levofloxacin (fluoroquinolone), penicillin, and minocycline (tetracycline), were used and the stroke patients were followed up to analyze the primary and secondary outcomes. It was concluded that early antibiotic therapy (mostly within 24 hours) leads to a reduced rate of post-stroke infections and reduced fever spikes, whereas follow-up for a longer period of time showed no better functional outcome. Furthermore, mortality and morbidity benefits were also not seen with prophylactic antibiotic therapy. This review helped us to put a nail in the coffin to the earlier thoughts that prophylactic antibiotics are necessary for the critical care of stroke patients.
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Affiliation(s)
- Muhammad Humayoun Rashid
- Neurology, Bakhtawar Amin Medical and Dental College, Multan, PAK.,Internal Medicine, Nishtar Medical University and Hospital, Multan, PAK
| | - Ahmad Kabir
- Pathology, Bakhtawar Amin Medical and Dental College, Multan, PAK.,Internal Medicine, Nishtar Hospital, Multan, PAK
| | | | - Umer Salman
- Internal Medicine, City Hospital, Multan, PAK
| | - Sarmad Zain
- Internal Medicine, Nishtar Hospital, Nishtar Medical University, Multan, PAK
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18
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Ye Z, Jin Y, Li H, Xu H, He Y, Chen Y. Association of Tim-4 expression in monocyte subtypes with clinical course and prognosis in acute ischemic stroke patients. Int J Neurosci 2020; 130:906-916. [PMID: 31877070 DOI: 10.1080/00207454.2019.1709842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: It has been proven that T cell immunoglobin and mucin domain (Tim)-4 and monocytes (Mo) are involved in regulation of immunity, which is important for the recovery of acute ischemic stroke (AIS).Methods: In this study, the expression of Tim-4 in both circulating Mo subtypes and plasma in 32 consecutive AIS patients and 32 control patients was assessed to determine their correlation with the clinical course and prognosis of AIS.Results: It was found that, compared to the control patients, the percentage of Tim-4 expression in overall Mo, classical Mo and non-classical Mo was significantly elevated after 2 and 5 days of stroke (p < 0.05), while it was promoted from 0 to 10 days of stoke in intermediate Mo (p < 0.05). Furthermore, Tim-4 expressions in non-classical Mo and intermediate Mo were obviously correlated with National Institutes of Health Stroke Scale (NIHSS) scores at 2 days of stroke (r = 0.351, p = 0.048; r = 0.358, p = 0.044, respectively). In poor outcome (PO) patients, the expression of Tim-4 in non-classical Mo was remarkably promoted at 2 days of stroke in comparison with non-PO patients (p < 0.05). More importantly, our results revealed a positive correlation between Tim-4 expression in non-classical Mo and interleukin (IL)-6 plasma levels in AIS patients without infection.Conclusion: In summary, our findings proved that Tim-4 expression in non-classical Mo could be an appropriate target for the prediction of the clinical course and prognosis in AIS patients.
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Affiliation(s)
- Zhinan Ye
- Department of Neurology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
| | - Yingying Jin
- Intensive Care Unit, Taizhou Hospital, Taizhou, Zhejiang, China
| | - Haijun Li
- Department of Neurology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
| | - Hao Xu
- Department of Neurology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
| | - Yingye He
- Department of Neurology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
| | - Ying Chen
- Department of Neurology, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
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19
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Smith CJ, Heal C, Vail A, Jeans AR, Westendorp WF, Nederkoorn PJ, van de Beek D, Kalra L, Montaner J, Woodhead M, Meisel A. Antibiotic Class and Outcome in Post-stroke Infections: An Individual Participant Data Pooled Analysis of VISTA-Acute. Front Neurol 2019; 10:504. [PMID: 31156537 PMCID: PMC6527959 DOI: 10.3389/fneur.2019.00504] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/26/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction: Antibiotics used to treat post-stroke infections have differing antimicrobial and anti-inflammatory effects. Our aim was to investigate whether antibiotic class was associated with outcome after post-stroke infection. Methods: We analyzed pooled individual participant data from the Virtual International Stroke Trials Archive (VISTA)-Acute. Patients with ischemic stroke and with an infection treated with systemic antibiotic therapy during the first 2 weeks after stroke onset were eligible. Antibiotics were grouped into eight classes, according to antimicrobial mechanism and prevalence. The primary analysis investigated whether antibiotic class for any infection, or for pneumonia, was independently associated with a shift in 90 day modified Rankin Scale (mRS) using ordinal logistic regression. Results: 2,708 patients were eligible (median age [IQR] = 74 [65 to 80] y; 51% female; median [IQR] NIHSS score = 15 [11 to 19]). Pneumonia occurred in 35%. Treatment with macrolides (5% of any infections; 9% of pneumonias) was independently associated with more favorable mRS distribution for any infection [OR (95% CI) = 0.59 (0.42 to 0.83), p = 0.004] and for pneumonia [OR (95% CI) = 0.46 (0.29 to 0.73), p = 0.001]. Unfavorable mRS distribution was independently associated with treatment of any infection either with carbapenems, cephalosporins or monobactams [OR (95% CI) = 1.62 (1.33 to 1.97), p < 0.001], penicillin plus β-lactamase inhibitors [OR (95% CI) = 1.26 (1.03 to 1.54), p = 0.025] or with aminoglycosides [OR (95% CI) = 1.73 (1.22 to 2.46), p = 0.002]. Conclusion: This retrospective study has several limitations including effect modification and confounding by indication. Macrolides may have favorable immune-modulatory effects in stroke-associated infections. Prospective evaluation of the impact of antibiotic class on treatment of post-stroke infections is warranted.
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Affiliation(s)
- Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, United Kingdom.,Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Calvin Heal
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Andy Vail
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Adam R Jeans
- Division of Clinical Support Services and Tertiary Medicine, Department of Microbiology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Willeke F Westendorp
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Lalit Kalra
- Clinical Neurosciences, King's College Hospital NHS Foundation Trust London, London, United Kingdom
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d' Hebron Institute of Research, Barcelona, Spain.,Stroke Research Program, Department of Neurology, Institute de Biomedicine of Seville, Hospital Universitario Virgen Macarena, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Mark Woodhead
- Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Andreas Meisel
- Department of Neurology, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité Universitaetsmedizin Berlin, Berlin, Germany
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20
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Abstract
Given the need for early restoration of blood flow and preservation of partially damaged brain cells after ischemic stroke, the noninterventional treatment of stroke relies heavily on the speedy recognition and classification of the clinical syndrome. Initiation of systemic thrombolysis with careful observation of contraindications within the 3.0 (4.5)-hour time window is the approved therapy of choice. Management of hemorrhagic complications and resumption of oral anticoagulation if indicated are also discussed in this article.
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21
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Vermeij JD, Westendorp WF, van de Beek D, Nederkoorn PJ. Post-stroke infections and preventive antibiotics in stroke: Update of clinical evidence. Int J Stroke 2018; 13:913-920. [PMID: 30175940 DOI: 10.1177/1747493018798557] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This review provides an update of evidence on post-stroke infections and the use of preventive antibiotics in stroke. Infection is a common complication after stroke, affecting between 15% and 30% of the patients. The predictors for post-stroke infection can be divided into three categories: clinical factors, anatomical (stroke related) factors and immunological factors. The relation between the occurrence of a post-stroke infection and functional outcome remained subject of debate, but it seems likely that the occurrence of these infections has a causal relation with poor functional outcome and mortality. In the first meta-analysis on preventive antibiotic therapy, almost a decade ago, its beneficial effect on post-stroke infection rate was clear; however, the effect on functional outcome remained uncertain because included studies were small and heterogeneous. Afterwards, three large phase-3 RCTs were published and a Cochrane meta-analysis was performed. It has now become clear that, despite the finding that overall infections are reduced, preventive antibiotic therapy in the acute phase of stroke does neither improve functional outcome, nor decrease mortality rates. This does not yet mean that further research on preventive antibiotics in stroke is useless: the pathophysiology and etiology of post-stroke infections are unclear and the use of preventive antibiotics in specific subgroups of stroke patients could still be very effective. This is currently being studied. Besides, preventive antibiotic therapy might be cost-effective by increasing quality-adjusted life years. Thirdly, research for the upcoming years might put more emphasis on the effect of stroke on immunological alterations.
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Affiliation(s)
- Jan-Dirk Vermeij
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Willeke F Westendorp
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
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Preventive Antibiotics for Poststroke Infection in Patients With Acute Stroke: A Systematic Review and Meta-analysis. Neurologist 2018; 23:35-42. [PMID: 29494432 DOI: 10.1097/nrl.0000000000000152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIMS To determine if preventive antibiotics is effective in poststroke infection in patients with acute stroke in comparison with no prophylaxis. MATERIALS AND METHODS MEDLINE (1950 to January 2017), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2017) and EMBASE (1974 to January 2017) databases were used to search for randomized controlled trials with intervening measures related to the preventive antibiotics in patients with acute stroke. Besides, the reference lists of the retrieved publications were manually searched to explore other relevant studies. RESULTS We included 6 randomized controlled trials involving 4110 stroke patients. The study population, study design, intervening measures, and definition of infection were different. Preventive antibiotics significantly reduced the incidence of algorithm-defined infection in patients with acute stroke from 11.14% (220/1975) to 7.43% (149/2006); odds ratio (OR)=0.41; 95% confidence interval (CI), 0.20-0.87; P=0.02. There was no difference in mortality between 2 groups, the mortality in preventive antibiotics group was 17.03% (347/2037) and control group was 16.10% (328/2037); OR=1.07; 95% CI, 0.90-1.27; P=0.44. And preventive antibiotics did not improve the proportion of good outcome, the proportion of good outcome in preventive antibiotics group was 45.47% (909/1999) and control group was 45.76% (913/1995); OR=0.89; 95% CI, 0.62-1.28; P=0.53. None of the studies reported severe adverse relevant to the study antibiotics. CONCLUSIONS Preventive antibiotics significantly reduced the incidence of algorithm-defined infection in patients with acute stroke, but did not decrease the mortality or improve the proportion of good outcome. Future research should aim to identify the group of stroke patients who will benefit most from antibiotic prophylaxis.
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Effectiveness and Safety of Antibiotics for Preventing Pneumonia and Improving Outcome after Acute Stroke: Systematic Review and Meta-analysis. J Stroke Cerebrovasc Dis 2018; 27:3137-3147. [PMID: 30093207 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 07/01/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pneumonia is a common complication after stroke which increases morbidity and mortality. This systematic review was conducted to evaluate the efficacy and safety of antibiotics for the prevention of pneumonia after acute stroke. METHODS Medline, EMBASE, and Cochrane databases were searched for randomized controlled trials comparing preventive antibiotics to placebo or no antibiotics after acute stroke. The primary outcome was poststroke pneumonia. Secondary outcomes were all infections, urinary tract infections, death, dependency, length of hospital stay, and adverse events. Treatment effects were summarized using random effects metaanalysis. RESULTS Six trials (4111 patients) were eligible for inclusion. The median National Institute of Health Stroke Scale score in included trials ranged from 5 to 16.5. The proportion of dysphagia ranged from 26% to 100%. Preventive antibiotics were commenced within 48hours after acute stroke. Compared to control, preventive antibiotics reduced the risk of poststroke pneumonia (RR .75, 95%CI ·.57-.99), and all infections (RR .58, 95%CI .48-.69). There was no significant difference in the risks of dependency (RR 0.99, 95%CI 0·80-1·11), or mortality (RR .96, 95%CI .78-1.19) between the preventive antibiotics and control groups. Preventive antibiotics did not increase the risk of elevated liver enzymes (RR 1.20, 95% CI .97-1.49). Preventive antibiotics had uncertain effects on the risks of other adverse events. CONCLUSION Preventive antibiotics reduced the risk of post-stroke pneumonia. However, there is insufficient evidence to currently recommend routine use of preventive antibiotics after acute stroke.
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Kishore AK, Vail A, Jeans AR, Chamorro A, Di Napoli M, Kalra L, Langhorne P, Roffe C, Westendorp W, Nederkoorn PJ, Garau J, van de Beek D, Montaner J, Woodhead M, Meisel A, Smith CJ. Microbiological Etiologies of Pneumonia Complicating Stroke. Stroke 2018; 49:1602-1609. [DOI: 10.1161/strokeaha.117.020250] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 05/02/2018] [Accepted: 05/14/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Amit K. Kishore
- From the Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, United Kingdom (A.K.K., C.J.S.)
- Division of Cardiovascular Sciences (A.K.K., C.J.S.)
| | - Andy Vail
- Centre for Biostatistics, Salford Royal Foundation Trust (A.V.)
| | - Adam R. Jeans
- University of Manchester, United Kingdom; Department of Microbiology, Salford Royal NHS Foundation Trust, United Kingdom (A.R.J.)
| | - Angel Chamorro
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, Spain (A.C.)
| | - Mario Di Napoli
- Neurological Service and Stroke Unit, San Camillo de’ Lellis General Hospital, Rieti, Italy (M.D.N.)
| | - Lalit Kalra
- Clinical Neurosciences, King’s College Hospital NHS Foundation Trust London, United Kingdom (L.K.)
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, Glasgow Royal Infirmary, University of Glasgow, United Kingdom (P.L.)
| | - Christine Roffe
- Keele University Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Stoke-on-Trent, United Kingdom (C.R.)
| | - Willeke Westendorp
- Department of Neurology, Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, Netherlands (W.W., P.J.N., D.v.d.B.)
| | - Paul J. Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, Netherlands (W.W., P.J.N., D.v.d.B.)
| | - Javier Garau
- Department of Medicine, Hospital Universitari Mutua de Terrassa, Barcelona, Spain (J.G.)
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, Netherlands (W.W., P.J.N., D.v.d.B.)
| | - Joan Montaner
- From the Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, United Kingdom (A.K.K., C.J.S.)
- Neurovascular Research Lab, Vall d’Hebron Research Institute, Barcelona, Spain (J.M.)
| | - Mark Woodhead
- Department of Respiratory Medicine, Faculty of Medical and Human Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester University NHS Foundation Trust, United Kingdom (M.W.)
| | - Andreas Meisel
- Department of Neurology, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité Universitaetsmedizin Berlin, Germany (A.M.)
| | - Craig J. Smith
- From the Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, United Kingdom (A.K.K., C.J.S.)
- Division of Cardiovascular Sciences (A.K.K., C.J.S.)
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Zhang Y, Wei L, Du Y, Xie Y, Wu W, Yuan Y. Association Between Programed Cell Death-1 and CD4 + T Cell Alterations in Different Phases of Ischemic Stroke Patients. Front Cell Neurosci 2018; 12:170. [PMID: 30013463 PMCID: PMC6036251 DOI: 10.3389/fncel.2018.00170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 05/31/2018] [Indexed: 12/12/2022] Open
Abstract
Objective: We aimed to analyze alterations in T cell subgroups during different post-ischemic stroke (IS) phases to explore the possible mechanisms underlying stroke-induced immune depression (SIID). Methods: Sixty-four IS patients who met the entry criteria were divided into three groups: an acute phase group, a sub-acute phase group and a stable phase group. Fourteen healthy individuals were selected as normal controls. The phenotype distribution of T cells in patient peripheral blood was analyzed, and the immune checkpoint receptors programed cell death-1 (PD-1) and T cell immunoglobulin and mucin domain 3 (Tim-3) were detected in different T cell phenotypes. Results: Compared with the control group, the absolute number of CD4+ T cells and CD4+ T central memory (TCM) cells was significantly increased in the acute phase group but decreased in the sub-acute phase and stable phase groups compared with that in the acute phase group. PD-1 expression in CD4+ T cells in the stable phase group showed a significant increase compared with that in the acute phase group. The expression of PD-1 on CD4+ TCM cells and CD4+ T effector memory (TEM) cells showed significant decreases in the acute phase compared with control cells; however, in the sub-acute phase and the stable phase, PD-1 expression was significantly increased compared with that in the acute phase. Conclusions: T cell dysfunction, especially CD4+ T cell dysfunction, occurred during different IS phases. PD-1 was highly expressed in CD4+ T cells of different phenotypes after the acute phase and was associated with alterations in CD4+ T cells. Particularly, PD-1 was negatively correlated with the absolute number of TCM cells among different CD4+ T cell phenotypes, which may be one of the possible mechanisms of SIID.
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Affiliation(s)
- Yi Zhang
- Department of Laboratory Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Li Wei
- State Key Laboratory of Diagnostic and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yupeng Du
- Department of Rehabilitation, The Third Affiliated Hospital, Zhejiang University of Traditional Chinese Medicine, Hangzhou, China
| | - Yirui Xie
- State Key Laboratory of Diagnostic and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Wu
- State Key Laboratory of Diagnostic and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuan Yuan
- Department of Neurology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Adrenal hormones and circulating leukocyte subtypes in stroke patients treated with reperfusion therapy. Brain Behav Immun 2018; 70:346-353. [PMID: 29548995 DOI: 10.1016/j.bbi.2018.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/03/2018] [Accepted: 03/12/2018] [Indexed: 11/23/2022] Open
Abstract
Ischemic stroke sets in motion a dialogue between the central nervous and the immune systems that includes the sympathetic/adrenal system. We investigated the course of immune cells and adrenocortical and adrenomedullary effectors in a cohort of 51 patients with acute stroke receiving reperfusion therapy (intravenous alteplase or mechanical thrombectomy) and its correlation with stroke outcomes and infarct growth. Cortisol increased rapidly and fleetingly after stroke, but 39% of patients who had larger infarctions on admission showed a positive delta cortisol at day 1. It was associated with enhanced infarct growth (p = 0.002) and poor outcome [OR (95% CI) 5.30 (1.30-21.69)], and correlated with less lymphocytes and T cells at follow up. Likewise, fewer circulating lymphocytes, T cells, and Tregs were associated with infarct growth. By contrast, metanephrines did not increase at clinical onset, and decreased over time. Higher levels of NMN correlated with more Treg and B cells. Eventually, complete reperfusion at the end of therapy headed the identification of more circulating Tregs at day 1. Then activation of cortical or medullar compartments of the adrenal gland result in specific signatures on leukocyte subpopulations. Manipulation of the adrenal gland hormone levels warrants further investigation.
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27
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Shim R, Wong CHY. Complex interplay of multiple biological systems that contribute to post-stroke infections. Brain Behav Immun 2018; 70:10-20. [PMID: 29571897 DOI: 10.1016/j.bbi.2018.03.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 02/08/2023] Open
Abstract
Stroke is a leading contributor of death and disability around the world. Despite its recognised debilitating neurological deficits, a devastating clinical complication of surviving stroke patients that needs more attention is infection. Up to half of the patients develop infections after stroke, and a high proportion of them will die as a direct consequence. Major clinical trials that examined preventive antibiotic therapy in stroke patients have demonstrated this method of prevention is not effective as it does not reduce incidence of post-stroke pneumonia or improve patient outcome. Additionally, retrospective studies evaluating the use of β-blockers for the modulation of the sympathetic nervous system to prevent post-stroke infections have given mixed results. Therefore, there is an urgent need for more effective therapeutic options that target the underlying mechanisms of post-stroke infections. The understanding that infections are largely attributable to the "stroke-induced systemic immunosuppression" phenomenon has begun to emerge, and thus, exploring the pathways that trigger post-stroke immunosuppression is expected to reveal potential new therapeutics. As such, we will outline the impacts that stroke has on several biological systems in this review, and discuss how these contribute to host susceptibility to infection after stroke. Furthermore, the emerging role of the gut and its microbiota has recently come to surface and intensifies the complex pathways to post-stroke infection. Finally, we identify potential avenues to combat infection that target the pathways of stroke-induced systemic immunosuppression to ultimately improve stroke patient outcome.
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Affiliation(s)
- Raymond Shim
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Connie H Y Wong
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Clayton, Victoria, Australia.
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28
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Jiang C, Kong W, Wang Y, Ziai W, Yang Q, Zuo F, Li F, Wang Y, Xu H, Li Q, Yang J, Lu H, Zhang J, Wang J. Changes in the cellular immune system and circulating inflammatory markers of stroke patients. Oncotarget 2018; 8:3553-3567. [PMID: 27682880 PMCID: PMC5356903 DOI: 10.18632/oncotarget.12201] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 09/16/2016] [Indexed: 01/09/2023] Open
Abstract
This study was designed to investigate dynamic changes in the cellular immune system and circulating inflammatory markers after ischemic stroke. Blood was collected from 96 patients and 99 age-matched control subjects for detection of lymphocyte subpopulations and inflammatory markers. We observed decreases in B cells, Th cells, cytotoxic T cells, and NK cells and an increase in regulatory T (Treg) cells in stroke patients on days 1, 3, and 7. Serum levels of TNF-α, C-reactive protein (CRP), IL-4, IL-6, IL-10, IL-17, IL-23, and TGF-β increased, whereas serum level of IFN-γ decreased at all time points after stroke. Stroke patients with infection exhibited a similar tendency toward changes in some lymphocyte subpopulations and inflammatory markers as stroke patients without infection. After controlling for NIH Stroke Scale (NIHSS), we observed no differences in lymphocyte subpopulations between patients with anterior circulation stroke and those with posterior circulation stroke at any time point. The splenic volume correlated positively with the percentages of B cells, Th cells, and cytotoxic T cells, but negatively with Treg cells on day 3 after stroke. Infections were associated with splenic volume, leukocyte counts, percentage of Treg cells, and serum levels of CRP, IL-10, and IFN-γ on day 3. Lesion volume correlated positively with CRP, IL-6, and IL-23, but negatively with IFN-γ on day 3. The NIHSS showed a positive relation with IL-6 and IL-10 on day 3. Ischemic stroke has a profound effect on the systemic immune system that might explain the increased susceptibility of stroke patients to infection.
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Affiliation(s)
- Chao Jiang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Weixia Kong
- Department of Ultrasonography, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yuejuan Wang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wendy Ziai
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Fangfang Zuo
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Fangfang Li
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yali Wang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Hongwei Xu
- Department of Radiology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Qian Li
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Jie Yang
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Hong Lu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jiewen Zhang
- Department of Neurology, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jian Wang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Shi K, Wood K, Shi FD, Wang X, Liu Q. Stroke-induced immunosuppression and poststroke infection. Stroke Vasc Neurol 2018; 3:34-41. [PMID: 29600006 PMCID: PMC5870641 DOI: 10.1136/svn-2017-000123] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/03/2017] [Accepted: 12/11/2017] [Indexed: 02/04/2023] Open
Abstract
Infections occur commonly after stroke and are strongly associated with an unfavourable functional outcome of these patients. Approaches for effective management of poststroke infection remain scarce, presenting an urgent need for preventive anti-infection strategies for patients who have suffered a stroke. Emerging evidence indicates that stroke impairs systemic immune responses and increases the susceptibility to infections, suggesting that the modification of impaired immune defence could be beneficial. In this review, we summarised previous attempts to prevent poststroke infections using prophylactic antibiotics and the current understanding of stroke-induced immunosuppression. Further elucidation of the immune mechanisms of stroke will pave the way to tailored design of new treatment to combat poststroke infection via modifying the immune system.
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Affiliation(s)
- Kaibin Shi
- Departments of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- Departments of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kristofer Wood
- Departments of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Fu-Dong Shi
- Departments of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- Departments of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
| | - Xiaoying Wang
- Departments of Neurology and Radiology, Neuroprotection Research Laboratory, Massachusetts General Hospital, Neuroscience Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Qiang Liu
- Departments of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- Departments of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA
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30
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Vermeij J, Westendorp WF, Dippel DWJ, van de Beek D, Nederkoorn PJ. Antibiotic therapy for preventing infections in people with acute stroke. Cochrane Database Syst Rev 2018; 1:CD008530. [PMID: 29355906 PMCID: PMC6491314 DOI: 10.1002/14651858.cd008530.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Stroke is the main cause of disability in high-income countries and ranks second as a cause of death worldwide. Infections occur frequently after stroke and may adversely affect outcome. Preventive antibiotic therapy in the acute phase of stroke may reduce the incidence of infections and improve outcome. In the previous version of this Cochrane Review, published in 2012, we found that antibiotics did reduce the risk of infection but did not reduce the number of dependent or deceased patients. However, included studies were small and heterogeneous. In 2015, two large clinical trials were published, warranting an update of this Review. OBJECTIVES To assess the effectiveness and safety of preventive antibiotic therapy in people with ischaemic or haemorrhagic stroke. We wished to determine whether preventive antibiotic therapy in people with acute stroke:• reduces the risk of a poor functional outcome (dependency and/or death) at follow-up;• reduces the occurrence of infections in the acute phase of stroke;• reduces the occurrence of elevated body temperature (temperature ≥ 38° C) in the acute phase of stroke;• reduces length of hospital stay; or• leads to an increased rate of serious adverse events, such as anaphylactic shock, skin rash, or colonisation with antibiotic-resistant micro-organisms. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (25 June 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 5; 25 June 2017) in the Cochrane Library; MEDLINE Ovid (1950 to 11 May 2017), and Embase Ovid (1980 to 11 May 2017). In an effort to identify further published, unpublished, and ongoing trials, we searched trials and research registers, scanned reference lists, and contacted trial authors, colleagues, and researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of preventive antibiotic therapy versus control (placebo or open control) in people with acute ischaemic or haemorrhagic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected articles and extracted data; we discussed and resolved discrepancies at a consensus meeting with a third review author. We contacted study authors to obtain missing data when required. An independent review author assessed risk of bias using the Cochrane 'Risk of bias' tool. We calculated risk ratios (RRs) for dichotomous outcomes, assessed heterogeneity amongst included studies, and performed subgroup analyses on study quality. MAIN RESULTS We included eight studies involving 4488 participants. Regarding quality of evidence, trials showed differences in study population, study design, type of antibiotic, and definition of infection; however, primary outcomes among the included studies were consistent. Mortality rate in the preventive antibiotic group was not significantly different from that in the control group (373/2208 (17%) vs 360/2214 (16%); RR 1.03, 95% confidence interval (CI) 0.87 to 1.21; high-quality evidence). The number of participants with a poor functional outcome (death or dependency) in the preventive antibiotic therapy group was also not significantly different from that in the control group (1158/2168 (53%) vs 1182/2164 (55%); RR 0.99, 95% CI 0.89 to 1.10; moderate-quality evidence). However, preventive antibiotic therapy did significantly reduce the incidence of 'overall' infections in participants with acute stroke from 26% to 19% (408/2161 (19%) vs 558/2156 (26%); RR 0.71, 95% CI 0.58 to 0.88; high-quality evidence). This finding was highly significant for urinary tract infections (81/2131 (4%) vs 204/2126 (10%); RR 0.40, 95% CI 0.32 to 0.51; high-quality evidence), whereas no preventive effect for pneumonia was found (222/2131 (10%) vs 235/2126 (11%); RR 0.95, 95% CI 0.80 to 1.13; high-quality evidence). No major side effects of preventive antibiotic therapy were reported. Only two studies qualitatively assessed the occurrence of elevated body temperature; therefore, these results could not be pooled. Only one study reported length of hospital stay. AUTHORS' CONCLUSIONS Preventive antibiotics had no effect on functional outcome or mortality, but significantly reduced the risk of 'overall' infections. This reduction was driven mainly by prevention of urinary tract infection; no effect for pneumonia was found.
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Affiliation(s)
- Jan‐Dirk Vermeij
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Willeke F Westendorp
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Diederik WJ Dippel
- Erasmus MC University Medical CenterPO Box 2040RotterdamNetherlands3000 CA
| | - Diederik van de Beek
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Paul J Nederkoorn
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
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31
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Nicholls AJ, Wen SW, Hall P, Hickey MJ, Wong CHY. Activation of the sympathetic nervous system modulates neutrophil function. J Leukoc Biol 2017; 103:295-309. [PMID: 29345350 PMCID: PMC6635748 DOI: 10.1002/jlb.3ma0517-194rr] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 10/04/2017] [Accepted: 12/06/2017] [Indexed: 01/19/2023] Open
Abstract
Emerging evidence has revealed that noradrenaline (NA), the main neurotransmitter of the sympathetic nervous system (SNS), regulates a variety of immune functions via binding to adrenergic receptors present on immune cells. In this study, we examined the role of NA in the regulation of neutrophil functions. Neutrophils were isolated from the bone marrow of naïve mice and treated with NA at various concentrations to assess the effect on various neutrophil functions. Additionally, we performed cremaster intravital microscopy to examine neutrophil‐endothelial cell interactions following NA superfusion in vivo. In a separate group of animals, mice were subjected to an experimental model of stroke and at 4 and 24 h neutrophils were isolated for assessment on their ability to migrate toward various chemokines. Treatment of neutrophils with NA for 4 h significantly impaired neutrophil chemotaxis and induced an N2 neutrophil phenotype with reduced expression of the genes critical for cytoskeleton remodeling and inflammation. Prolonged NA administration promoted neutrophils to release myeloperoxidase and IL‐6, but suppressed the production of interferon‐γ and IL‐10, reduced neutrophil activation and phagocytosis. Superfusion of NA over the cremaster muscle almost completely inhibited fMLP‐induced neutrophil adhesion/arrest and transmigration. Furthermore, using a mouse model of stroke, a pathological condition in which SNS activation is evident, neutrophils isolated from poststroke mice showed markedly reduced chemotaxis toward all of the chemokines tested. The findings from our study indicate that neutrophil chemotaxis, activation, and phagocytosis can all be negatively regulated in an NA‐dependent manner. A better understanding of the relationship between sympathetic activation and neutrophil function will be important for the development of effective antibacterial interventions.
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Affiliation(s)
- Alyce J Nicholls
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Australia
| | - Shu Wen Wen
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Australia
| | - Pam Hall
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Australia
| | - Michael J Hickey
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Australia
| | - Connie H Y Wong
- Centre for Inflammatory Diseases, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Australia
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Zheng F, von Spreckelsen N, Zhang X, Stavrinou P, Timmer M, Dohmen C, Goldbrunner R, Cao F, Zhang Q, Ran Q, Li G, Fan R, Yao S, Krischek B. Should preventive antibiotics be used in patients with acute stroke? A systematic review and meta-analysis of randomized controlled trials. PLoS One 2017; 12:e0186607. [PMID: 29049353 PMCID: PMC5648227 DOI: 10.1371/journal.pone.0186607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/04/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Infection is a common complication in acute stroke. Whether or not preventive antibiotics reduce the risk of infection or even lead to a favorable outcome and reduction of mortality after a stroke still remains equivocal. This review was performed to update the current knowledge on the effect and possible benefits of prophylactic antibiotic therapy in patients with stroke. METHODS A systematic review and meta-analysis of preventive antibiotics`effect on the incidence of infection, favorable outcome (mRS≤2) and mortality in patients with acute stroke is performed with relevant randomized controlled trials. RESULTS Six studies were identified, involving 4125 participants. Compared with the control group, the treated groups were significantly less prone to suffer from early overall infections [RR = 0.52, 95%CI (0.39, 0.70), p<0.0001], early pneumonia [RR = 0.64, 95%CI (0.42, 0.96), p = 0.03] and early urinary tract infections [RR = 0.35, 95%CI (0.25, 0.48), p<0.00001]. However, there was no significant difference in overall mortality [RR = 1.07, 95%CI (0.90, 1.27), p = 0.44], early mortality [RR = 0.99, 95%CI (0.78, 1.26), p = 0.92], late mortality [RR = 1.12, 95%CI (0.94, 1.35), p = 0.21] or favorable outcome [RR = 1.00, 95%CI (0.92, 1.08), p = 0.98]. CONCLUSION Although preventive antibiotic treatment did reduce the occurrence of early overall infections, early pneumonia and early urinary tract infection in patients with acute stroke, this advantage was not eventually translated to a favorable outcome and reduction in mortality. Future studies are warranted to identify any subgroup of stroke patients who might benefit from preventive antibiotic treatment.
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Affiliation(s)
- Feng Zheng
- Department of Neurosurgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
- * E-mail: (BK); (FZ)
| | | | - Xintong Zhang
- Department of Neurosurgery, The Second Clinical Medical School of Inner Mongolia University for the Nationalities (Inner Mongolia Forestry General Hospital), Inner Mongolia, China
| | - Pantelis Stavrinou
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Marco Timmer
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Dohmen
- Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Fang Cao
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qiang Zhang
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qishan Ran
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Gang Li
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Ruiming Fan
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Shengtao Yao
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Boris Krischek
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
- * E-mail: (BK); (FZ)
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Xi YG, Tian X, Chen WQ, Zhang S, Zhang S, Ren WD, Pang QJ, Yang GT, Yang ZM. Antibiotic prophylaxis for infections in patients with acute stroke: a systematic review and meta-analysis of randomized controlled trials. Oncotarget 2017; 8:81075-81087. [PMID: 29113368 PMCID: PMC5655263 DOI: 10.18632/oncotarget.19039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/17/2017] [Indexed: 12/18/2022] Open
Abstract
Objective Infections are frequent after stroke and lead to increased mortality and neurological disability. Antibiotic prophylaxis has potential of decreasing the risk of infections and mortality and improving poor functional outcome. Several studies evaluated antibiotic prophylaxis for infections in acute stroke patients have generated conflicting results. The systematic review of randomized clinical trials (RCTs) aimed at comprehensively assessing the evidence of antibiotic prophylaxis for the treatment of acute stroke patients. Materials and Methods PubMed, EMBASE, the Cochrane library and the reference lists of eligible articles were searched to identify all potential studies. We included the studies that investigated the efficacy and safety of antibiotic prophylaxis for the treatment of acute stroke patients. The primary outcome included mortality and infection rate. The secondary outcomes included poor functional outcome and adverse events. Results Seven trials randomizing 4,261 patients were included. Pooled analyses showed that antibiotic prophylaxis did not improve the mortality (risk ratio (RR) = 1.03, 95% confidence interval (CI) 0.84 to 1.26, p = 0.78, I2 = 25%) and poor functional outcome (RR = 0.93, 95% CI 0.80 to 1.08, p = 0.32, I2 = 80%), but reduced the incidence of infection (RR = 0.67, 95% CI 0.53 to 0.84, p = 0.0007, I2 = 49%). No major side effects were reported. Sensitivity analyses confirmed the results of infection rate and poor functional outcome. Conclusions Antibiotic prophylaxis can be used to treat the infectious events of acute stroke patients although it has no potential of decreased mortality and improved functional outcome.
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Affiliation(s)
- Yan-Guo Xi
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Xu Tian
- Department of Gastroenterology, Chongqing Cancer Institute and Hospital and Cancer Center, Chongqing 400030, China
| | - Wei-Qing Chen
- Department of Gastroenterology, Chongqing Cancer Institute and Hospital and Cancer Center, Chongqing 400030, China
| | - Sai Zhang
- Department of Neurosurgery, Logistic University Affiliated Hospital, Logistic University of Chinese People's Armed Police Force, Tianjin 300162, China
| | - Shan Zhang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Wei-Dan Ren
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Qi-Jun Pang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Guo-Tao Yang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Zhi-Ming Yang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
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Santos Samary C, Pelosi P, Leme Silva P, Rieken Macedo Rocco P. Immunomodulation after ischemic stroke: potential mechanisms and implications for therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:391. [PMID: 27923376 PMCID: PMC5141640 DOI: 10.1186/s13054-016-1573-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Brain injuries are often associated with intensive care admissions, and carry high morbidity and mortality rates. Ischemic stroke is one of the most frequent causes of injury to the central nervous system. It is now increasingly clear that human stroke causes multi-organ systemic disease. Brain inflammation may lead to opposing local and systemic effects. Suppression of systemic immunity by the nervous system could protect the brain from additional inflammatory damage; however, it may increase the susceptibility to infection. Pneumonia and urinary tract infection are the most common complications occurring in patients after stroke. The mechanisms involved in lung-brain interactions are still unknown, but some studies have suggested that inhibition of the cholinergic anti-inflammatory pathway and release of glucocorticoids, catecholamines, and damage-associated molecular patterns (DAMPs) are among the pathophysiological mechanisms involved in communication from the ischemic brain to the lungs after stroke. This review describes the modifications in local and systemic immunity that occur after stroke, outlines mechanisms of stroke-induced immunosuppression and their role in pneumonia, and highlights potential therapeutic targets to reduce post-stroke complications. Despite significant advances towards a better understanding of the pathophysiology of ischemic stroke-induced immunosuppression and stroke-associated pneumonia (SAP) in recent years, many unanswered questions remain. The true incidence and outcomes of SAP, especially in intensive care unit settings, have yet to be determined, as has the full extent of stroke-induced immunosuppression and its clinical implications.
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Affiliation(s)
- Cynthia Santos Samary
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, 21941-902, Rio de Janeiro, RJ, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, 21941-902, Rio de Janeiro, RJ, Brazil
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, 21941-902, Rio de Janeiro, RJ, Brazil.
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The Efficacy of Prophylactic Antibiotics on Post-Stroke Infections: An Updated Systematic Review and Meta-Analysis. Sci Rep 2016; 6:36656. [PMID: 27841284 PMCID: PMC5107889 DOI: 10.1038/srep36656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/18/2016] [Indexed: 11/21/2022] Open
Abstract
Post-stroke infections are common complications in acute stroke patients and are associated with an unfavorable functional outcome. However, reports on the effects of prophylactic antibiotics treatment on post-stroke infections are conflicting, especially those on post-stroke pneumonia and outcomes. We searched the PubMed, Embase, and Web of Knowledge databases up through March 11th, 2016. Seven randomized controlled trials including 4261 patients were analyzed among this systematic review and meta-analysis. We found preventive antibiotics treatment at the time of stroke onset did reduce the incidence of infections in adults with acute stroke (OR = 0.57, 95% CI: 0.38–0.85, P = 0.005), including reducing the number of urinary tract infections (OR = 0.34, 95% CI: 0.26–0.46, P < 0.001), but did not significantly decrease the rate of post-stroke pneumonia (OR = 0.91, 95% CI: 0.73–1.13, P = 0.385). Importantly, antibiotics treatment also showed no significant effect on the number of fatalities among stroke patients (OR = 1.07, 95% CI: 0.90–1.26, P = 0.743) and functional outcome scores on the modified Rankin Scale (OR = 1.76, 95% CI: 0.86–3.63, p = 0.124). Our study indicated that preventive antibiotics treatment not reduced the rate of post-stroke pneumonia or mortality, even though decreased the risk of infections, especially urinary tract infections. Thus, preventive antibiotics treatment may not be recommended for acute stroke patients.
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Guillon B, Bourcier R, Toulgoat F, de Gaalon S, Gaultier-Lintia A, Sévin M. Gestione dell’infarto cerebrale acuto. Neurologia 2016. [DOI: 10.1016/s1634-7072(16)80382-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Pagram H, Bivard A, Lincz LF, Levi C. Immunity and stroke, the hurdles of stroke research translation. Int J Stroke 2016; 12:123-131. [PMID: 27784822 DOI: 10.1177/1747493016676622] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Immunomodulatory therapies after stroke have the potential to provide clinical benefit to a subset of patients, but risk subverting the protective, healing aspects of the innate immune response. Neutrophils clear necrotic cerebral tissue and are important in immunomodulation, but can also contribute to tissue injury. Human trials for immunomodulatory stroke treatments in the sub-acute time frame have attempted to prevent peripheral neutrophil infiltration, but none have been successful and one trial demonstrated harm. These unselected trials had broad inclusion criteria and appear to not have had a specific treatment target. Unfortunately, due to the heterogeneous nature of brain ischemia in humans resulting in variation in clinical severity, the negative effect of thrombolytic drugs on the blood-brain barrier, and the heterogeneity of immune response, it may only be a subset of stroke patients who can realistically benefit from immunomodulation therapies. Translational research strategies require both an understanding of lab practices which create highly controlled environments in contrast to clinical practice where the diagnosis of stroke does not require the identification of a vessel occlusion. These differences between lab and clinical practices can be resolved through the integration of appropriate patient selection criteria and use of advanced imaging and ridged patient selection practices in clinical trials which will be an important part to the success of any future trials of translational research such as immunomodulation.
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Affiliation(s)
- Heather Pagram
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia
| | - Andrew Bivard
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia
| | - Lisa F Lincz
- 2 Hunter Haematology Research Group, Calvary Mater Newcastle Hospital, Waratah, Australia
| | - Christopher Levi
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia
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Abstract
Infections, in particular pneumonia, are common complications in patients with acute stroke and are associated with a less favorable neurologic and functional outcome. Patients with severe stroke and dysphagia are at highest risk of infection. Experimental and clinical data suggest stroke-induced immunodeficiency as a major factor contributing to the high incidence of infection after stroke. Preclinical studies support the potential benefit of preventive antibiotic therapy in acute stroke for lowering the incidence of infection and improving clinical outcome. Several smaller clinical trials on preventive antibiotic therapy in patients with stroke conducted during the last 10 years yielded inconclusive results. Recently, 2 large, open-label, controlled trials failed to demonstrate an improved clinical outcome after preventive antibiotic therapy in patients with acute stroke treated in specialized stroke units. In the "Preventive Antibiotics in Stroke Study", antibiotic therapy lowered the rate of infection but did not influence outcome. In the STROKE-INF study, performed in patients with dysphagia after stroke, antibiotic therapy did not lower the incidence of pneumonia and had no prognostic significance. At present, preventive antibiotic therapy cannot be recommended as a therapeutic option for acute stroke.
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Affiliation(s)
- Stefan Schwarz
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany.
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Tziomalos K, Ntaios G, Miyakis S, Papanas N, Xanthis A, Agapakis D, Milionis H, Savopoulos C, Maltezos E, Hatzitolios AI. Prophylactic antibiotic treatment in severe acute ischemic stroke: the Antimicrobial chemopRrophylaxis for Ischemic STrokE In MaceDonIa-Thrace Study (ARISTEIDIS). Intern Emerg Med 2016; 11:953-8. [PMID: 27216796 DOI: 10.1007/s11739-016-1462-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/06/2016] [Indexed: 10/21/2022]
Abstract
Infections represent a leading cause of mortality in patients with acute ischemic stroke, but it is unclear whether prophylactic antibiotic treatment improves the outcome. We aimed to evaluate the effects of this treatment on infection incidence and short-term mortality. This was a pragmatic, prospective multicenter real-world analysis of previously independent consecutive patients with acute ischemic stroke who were >18 years, and who had at admission National Institutes of Health Stroke Scale (NIHSS) >11. Patients with infection at admission or during the preceding month, with axillary temperature at admission >37 °C, with chronic inflammatory diseases or under treatment with corticosteroids were excluded from the study. Among 110 patients (44.5 % males, 80.2 ± 6.8 years), 31 (28.2 %) received prophylactic antibiotic treatment, mostly cefuroxime (n = 21). Prophylactic antibiotic treatment was administered to 51.4 % of patients who developed infection, and to 16.4 % of patients who did not (p < 0.001). Independent predictors of infection were NIHSS at admission [relative risk (RR) 1.16, 95 % confidence interval (CI) 1.08-1.26, p < 0.001] and prophylactic antibiotic treatment (RR 5.84, 95 % CI 2.03-16.79, p < 0.001). The proportion of patients who received prophylactic antibiotic treatment did not differ between patients who died during hospitalization and those discharged, or between patients who died during hospitalization or during follow-up and those who were alive 3 months after discharge. Prophylactic administration of antibiotics in patients with severe acute ischemic stroke is associated with an increased risk of infection during hospitalization, and does not affect short-term mortality risk.
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Affiliation(s)
- Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Ntaios
- Department of Medicine, Larissa University Hospital, Medical School, University of Thessaly, Larissa, 41110, Greece.
| | - Spiros Miyakis
- Third Department of Internal Medicine, Papageorgiou Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Papanas
- Second Department of Internal Medicine, University Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Andreas Xanthis
- Department of Internal Medicine, General Hospital of Drama, Drama, Greece
| | - Dimitrios Agapakis
- Department of Internal Medicine, General Hospital of Goumenissa, Goumenissa, Greece
| | - Haralampos Milionis
- Department of Medicine, Ioannina University Hospital, Medical School, University of Ioannina, Ioannina, Greece
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efstratios Maltezos
- Second Department of Internal Medicine, University Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Apostolos I Hatzitolios
- First Propedeutic Department of Internal Medicine, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Ye S, Lin SP, Wu K, Fan Y, Xu M. Serum prealbumin is a predictive biomarker for stroke-associated infection after an ischemic stroke. Int J Neurosci 2016; 127:601-605. [PMID: 27476523 DOI: 10.1080/00207454.2016.1218874] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several prior studies have linked serum prealbumin (PA) as a predictor for perioperative infection. However, whether peripheral blood PA levels can be used as an indicator of stroke-associated infection (SAI) is still unclear. In this study, we attempt to find whether serum PA is a meaningful predictor in SAI after an ischemic stroke, so as to provide theoretical basis for clinical treatment. METHODS Consecutive patients with acute ischemic stroke who were admitted to our hospital were enrolled and serum PA was collected. A prospective study was conducted to observe the predictive value of PA in the SAI incident in ischemic stroke patients. RESULTS Of 104 patients, 29 (27.9%) developed an SAI after 7 d of follow-up. The stroke with SAI group had significantly lower PA levels than the stroke without SAI group ( p < 0.05). The optimal cutoff value for predicting SAI was PA ≤ 191 mg/L, with sensitivity and specificity of 58.62% and 81.33%, respectively. Kaplan-Meier survival analysis showed that stroke patients with low serum PA level (PA ≤ 191 mg/L) had a higher SAI rates (log-rank test, χ2 = 16.870, p < 0.001). Cox regression analysis showed that PA ≤ 191 mg/L (hazard ratio = 3.207; 95% CI, 1.430-7.190, p = 0.005) was an independent risk factor for SAI. CONCLUSIONS Early detection of serum PA during the acute phase of ischemic stroke may help us to identify at-risk SAI patients, and hence rapidly guide the intervention to prevent SAI.
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Affiliation(s)
- Shan Ye
- a Department of Geriatrics , The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China
| | - Shao-Peng Lin
- b Department of Emergency , The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China
| | - Keping Wu
- c Department of Neurology , The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Yongxiang Fan
- c Department of Neurology , The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , Guangdong Province , China
| | - Miqing Xu
- a Department of Geriatrics , The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China
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Increased expression of microRNA-21 in peripheral blood mediates the down-regulation of IFN-γ and increases the prevalence of stroke-associated infection. J Neurol Sci 2016; 366:235-239. [DOI: 10.1016/j.jns.2016.03.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/13/2016] [Accepted: 03/21/2016] [Indexed: 11/22/2022]
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Vermeij JD, Westendorp WF, Roos YB, Brouwer MC, van de Beek D, Nederkoorn PJ. Preventive Ceftriaxone in Patients with Stroke Treated with Intravenous Thrombolysis: Post Hoc Analysis of the Preventive Antibiotics in Stroke Study. Cerebrovasc Dis 2016; 42:361-369. [PMID: 27336314 DOI: 10.1159/000446160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/10/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The Preventive Antibiotics in Stroke Study (PASS), a randomized open-label masked endpoint trial, showed that preventive ceftriaxone did not improve functional outcome at 3 months in patients with acute stroke (adjusted common OR 0.95; 95% CI 0.82-1.09). Post-hoc analyses showed that among patients who received intravenous thrombolysis (IVT), patients who received ceftriaxone had a significantly better outcome as compared with the control group. This study aimed to gain more insight into the characteristics of these patients. METHODS In PASS, 2,550 patients were randomly assigned to preventive antibiotic treatment with ceftriaxone or standard care. In current post-hoc analysis, 836 patients who received IVT were included. Primary outcome included functional status on the modified Rankin Scale, analyzed with adjusted ordinal regression. Secondary outcomes included infection rate and symptomatic intracerebral hemorrhage (sICH) rate. RESULTS For all patients in PASS, the p value for the interaction between IVT and preventive ceftriaxone regarding functional outcome was 0.03. Of the 836 IVT-treated patients, 437 were administered ceftriaxone and 399 were allocated to the control group. Baseline characteristics were similar. In the IVT subgroup, preventive ceftriaxone was associated with a significant reduction in unfavorable outcome (adjusted common OR 0.77; 95% CI 0.61-0.99; p = 0.04). Mortality at 3 months was similar (OR 0.75; 95% CI 0.48-1.18). Preventive ceftriaxone was associated with a reduction in infections (OR 0.43; 95% CI 0.28-0.66), and a trend towards an increased risk for sICH (OR 3.09; 95% CI 0.85-11.31). Timing of ceftriaxone administration did not influence the outcome (aOR 1.00; 95% CI 0.98-1.03; p = 0.85). CONCLUSIONS According to the post-hoc analysis of PASS, preventive ceftriaxone may improve the functional outcome in IVT-treated patients with acute stroke, despite a trend towards an increased rate of post-IVT-sICH.
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Affiliation(s)
- Jan-Dirk Vermeij
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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The contribution of antibiotics, pneumonia and the immune response to stroke outcome. J Neuroimmunol 2016; 295-296:68-74. [PMID: 27235351 DOI: 10.1016/j.jneuroim.2016.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/05/2016] [Accepted: 04/07/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Infections are common following stroke and associated with worse outcome. Using an animal model of pneumonia, we assessed the effect of infection and its treatment on the immune response and stroke outcome. METHODS Lewis rats were subjected to transient cerebral ischemia and survived for 4weeks. One day after stroke animals were exposed to aerosolized Staphylococcus aureus, Pseudomonas aeruginosa or saline. Antibiotics (ceftiofur or enrofloxacin) were started immediately after exposure or delayed for 3days. Behavioral tests were performed weekly. ELISPOT assays were done on lymphocytes from spleen and brain to assess autoimmune responses to myelin basic protein (MBP). RESULTS Among animals that received immediate antibiotic therapy, infection was associated with worse outcome in ceftiofur but not enrofloxacin treated animals. (The outcome with immediate enrofloxacin therapy was so impaired that further worsening may have been difficult to detect.) A delay in antibiotic therapy was associated with better outcomes in both ceftiofur and enrofloxacin treated animals. Infection was associated with an increased likelihood of developing Th1(+) responses to MBP in non-infarcted brain (OR=2.94 [1.07, 8.12]; P=0.04), and Th1(+) responses to MBP in spleen and non-infarcted brain were independently associated with a decreased likelihood of stroke recovery (OR=0.16 [0.05, 0.51; P=0.002 and OR=0.32 [0.12, 0.84]; P=0.02, respectively). CONCLUSIONS Infection worsens stroke outcome in ceftiofur treated animals and increases Th1 responses to MBP. These data may help explain how infection worsens stroke outcome and suggest that treatment of infection may contribute to this outcome.
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Bustamante A, García-Berrocoso T, Rodriguez N, Llombart V, Ribó M, Molina C, Montaner J. Ischemic stroke outcome: A review of the influence of post-stroke complications within the different scenarios of stroke care. Eur J Intern Med 2016; 29:9-21. [PMID: 26723523 DOI: 10.1016/j.ejim.2015.11.030] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 09/28/2015] [Accepted: 11/30/2015] [Indexed: 12/21/2022]
Abstract
Stroke remains one of the main causes of death and disability worldwide. The challenge of predicting stroke outcome has been traditionally assessed from a general point of view, where baseline non-modifiable factors such as age or stroke severity are considered the most relevant factors. However, after stroke occurrence, some specific complications such as hemorrhagic transformations or post stroke infections, which lead to a poor outcome, could be developed. An early prediction or identification of these circumstances, based on predictive models including clinical information, could be useful for physicians to individualize and improve stroke care. Furthermore, the addition of biological information such as blood biomarkers or genetic polymorphisms over these predictive models could improve their prognostic value. In this review, we focus on describing the different post-stroke complications that have an impact in short and long-term outcome across different time points in its natural history and on the clinical-biological information that might be useful in their prediction.
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Affiliation(s)
- Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Teresa García-Berrocoso
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Noelia Rodriguez
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Victor Llombart
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos Molina
- Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Spain; Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Cohen DL, Roffe C, Beavan J, Blackett B, Fairfield CA, Hamdy S, Havard D, McFarlane M, McLauglin C, Randall M, Robson K, Scutt P, Smith C, Smithard D, Sprigg N, Warusevitane A, Watkins C, Woodhouse L, Bath PM. Post-stroke dysphagia: A review and design considerations for future trials. Int J Stroke 2016; 11:399-411. [PMID: 27006423 DOI: 10.1177/1747493016639057] [Citation(s) in RCA: 234] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 12/21/2015] [Indexed: 12/14/2022]
Abstract
Post-stroke dysphagia (a difficulty in swallowing after a stroke) is a common and expensive complication of acute stroke and is associated with increased mortality, morbidity, and institutionalization due in part to aspiration, pneumonia, and malnutrition. Although most patients recover swallowing spontaneously, a significant minority still have dysphagia at six months. Although multiple advances have been made in the hyperacute treatment of stroke and secondary prevention, the management of dysphagia post-stroke remains a neglected area of research, and its optimal management, including diagnosis, investigation and treatment, have still to be defined.
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Affiliation(s)
| | - Christine Roffe
- Stroke Research, University Hospital of North Midlands, Keele University, UK
| | | | | | - Carol A Fairfield
- School of Psychology and Clinical Language Sciences, University of Reading, UK
| | - Shaheen Hamdy
- Institute of Inflammation and Repair, University of Manchester, UK
| | - Di Havard
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | | | | | | | - Katie Robson
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | - Craig Smith
- Stroke and Vascular Research Centre, University of Manchester, UK
| | - David Smithard
- Elderly Medicine, Princess Royal University Hospital, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | | | - Caroline Watkins
- College of Health and Wellbeing, University of Central Lancashire, UK
| | - Lisa Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
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46
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Shim R, Wong CHY. Ischemia, Immunosuppression and Infection--Tackling the Predicaments of Post-Stroke Complications. Int J Mol Sci 2016; 17:ijms17010064. [PMID: 26742037 PMCID: PMC4730309 DOI: 10.3390/ijms17010064] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 12/14/2015] [Accepted: 12/24/2015] [Indexed: 12/29/2022] Open
Abstract
The incidence of stroke has risen over the past decade and will continue to be one of the leading causes of death and disability worldwide. While a large portion of immediate death following stroke is due to cerebral infarction and neurological complications, the most common medical complication in stroke patients is infection. In fact, infections, such as pneumonia and urinary tract infections, greatly worsen the clinical outcome of stroke patients. Recent evidence suggests that the disrupted interplay between the central nervous system and immune system contributes to the development of infection after stroke. The suppression of systemic immunity by the nervous system is thought to protect the brain from further inflammatory insult, yet this comes at the cost of increased susceptibility to infection after stroke. To improve patient outcome, there have been attempts to lessen the stroke-associated bacterial burden through the prophylactic use of broad-spectrum antibiotics. However, preventative antibiotic treatments have been unsuccessful, and therefore have been discouraged. Additionally, with the ever-rising obstacle of antibiotic-resistance, future therapeutic options to reverse immune impairment after stroke by augmentation of host immunity may be a viable alternative option. However, cautionary steps are required to ensure that collateral ischemic damage caused by cerebral inflammation remains minimal.
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Affiliation(s)
- Raymond Shim
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Clayton, VIC 3168, Australia.
| | - Connie H Y Wong
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Clayton, VIC 3168, Australia.
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47
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Tatlisumak T, Roine RO. General Stroke Management and Stroke Units. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00053-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Approaches for the effective management of acute stroke are sparse, and many measures for brain protection fail. However, our ability to modulate the immune system and modify the progression of multiple sclerosis is increasing. As a result, immune interventions are currently being explored as therapeutic interventions in acute stroke. In this Review, we compare the immunological features of acute stroke with those of multiple sclerosis, identify unique immunological features of stroke, and consider the evidence for immune interventions. In patients with acute stroke, microglial activation and cell death products trigger an inflammatory cascade that damages vessels and the parenchyma within minutes to hours of the ischaemia or haemorrhage. Immune interventions that restrict brain inflammation, vascular permeability and tissue oedema must be administered rapidly to reduce acute immune-mediated destruction and to avoid subsequent immunosuppression. Preliminary results suggest that the use of drugs that modify disease in multiple sclerosis might accomplish these goals in ischaemic and haemorrhagic stroke. Further elucidation of the immune mechanisms involved in stroke is likely to lead to successful immune interventions.
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Affiliation(s)
- Ying Fu
- Departments of Neurology and Immunology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China (Y.F., Q.L., F.-D.S.); Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 525 East 68th Street, PO Box 117, New York, NY 10065, USA. (J.A.)
| | - Qiang Liu
- Departments of Neurology and Immunology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China (Y.F., Q.L., F.-D.S.); Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 525 East 68th Street, PO Box 117, New York, NY 10065, USA. (J.A.)
| | - Josef Anrather
- Departments of Neurology and Immunology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China (Y.F., Q.L., F.-D.S.); Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 525 East 68th Street, PO Box 117, New York, NY 10065, USA. (J.A.)
| | - Fu-Dong Shi
- Departments of Neurology and Immunology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin 300052, China (Y.F., Q.L., F.-D.S.); Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 525 East 68th Street, PO Box 117, New York, NY 10065, USA. (J.A.)
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49
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Azurmendi L, Degos V, Tiberti N, Kapandji N, Sanchez P, Sarrafzadeh A, Puybasset L, Turck N, Sanchez JC. Measuring Serum Amyloid A for Infection Prediction in Aneurysmal Subarachnoid Hemorrhage. J Proteome Res 2015. [PMID: 26198378 DOI: 10.1021/acs.jproteome.5b00391] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high rates of mortality and morbidity. Nosocomial infections, such as pneumonia or urinary tract infections, are among the main causes of worsening outcomes and death. The aim of this study was to discover a biomarker to predict infection in aSAH patients. For this purpose, the plasma of infected and noninfected patients was compared using quantitative mass spectrometry. The most interesting differentially expressed proteins were selected for validation by immunoassays on plasma samples taken from patients (n = 81) over 10 days of hospitalization. Predictive performances were established using Mann-Whitney U tests and receiver operating characteristic curves. Quantitative proteomics identified 17 significantly regulated proteins. Of these, levels of serum amyloid A (SAA) were significantly higher in infected patients (p < 0.007). ELISA confirmed that the concentrations were significantly higher (p < 0.002) already at hospital admission in patients who subsequently developed an infection during their hospitalization, (AUC of 76%) for a cutoff value of 90.9 μg/mL. Our data suggested that measuring SAA could be an efficient means of detecting patients susceptible of developing an infection during hospitalization after an aSAH. Its predictive capacity could lead to earlier antibiotherapy, improved patient management, and potentially better long-term outcomes.
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Affiliation(s)
- Leire Azurmendi
- Department of Human Protein Sciences, University of Geneva , Rue Michel Servet 1, CH-1211 Geneva, Switzerland
| | - Vincent Degos
- Department of Anesthesiology, Pitié-Salpêtrière University Hospital , 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - Natalia Tiberti
- Department of Pathology, University of Sydney , Sydney NSW 2006, Australia
| | - Natacha Kapandji
- Department of Anesthesiology, Pitié-Salpêtrière University Hospital , 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - Paola Sanchez
- Department of Anesthesiology, Pitié-Salpêtrière University Hospital , 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - Asita Sarrafzadeh
- Department of Neurosurgery, Heidelberg University Hospital , Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Louis Puybasset
- Department of Anesthesiology, Pitié-Salpêtrière University Hospital , 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - Natacha Turck
- Department of Human Protein Sciences, University of Geneva , Rue Michel Servet 1, CH-1211 Geneva, Switzerland
| | - Jean-Charles Sanchez
- Department of Human Protein Sciences, University of Geneva , Rue Michel Servet 1, CH-1211 Geneva, Switzerland
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50
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Bruening T, Al-Khaled M. Stroke-Associated Pneumonia in Thrombolyzed Patients: Incidence and Outcome. J Stroke Cerebrovasc Dis 2015; 24:1724-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 11/22/2014] [Accepted: 03/15/2015] [Indexed: 11/27/2022] Open
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