Hyperglycemia in stroke and possible treatments

Nonlinear association between hemoglobin glycation index and mortality in ischemic stroke Patients: Insights from the MIMIC-IV database

AIMS

Hemoglobin glycation index (HGI) is closely associated with adverse outcomes in several diseases. However, few studies have investigated the correlation between HGI and prognosis in patients with critical ischemic stroke.

METHODS

A cohort of patients was established from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Kaplan-Meier analysis, multivariate regression models, and restricted cubic splines (RCS) were used to investigate the associations between HGI and different outcomes. Mediation models were constructed to determine the mediating role of white blood cell (WBC) counts.

RESULTS

This study included 2,332 participants. In-hospital mortality differs significantly across HGI groups (24.43 %, 11.82 %, and 10.14 %, P < 0.001). Multivariate regression analyses found that lower HGI was significantly associated with greater mortality risk. Nonlinear analyses revealed an L-shaped association between HGI and short-term mortality (30-day and in-hospital), while a reverse J-shaped relationship emerged for long-term (365-day) mortality. Mediation analysis revealed that WBC counts mediated the association with proportions (%) of 33.73, 19.65, and 30.00, respectively.

CONCLUSION

Lower HGI is consistently related to poorer outcomes in patients with critical ischemic stroke. Higher HGI could be a protective factor in the short term but might increase mortality risk in the long term. WBC counts significantly mediate the association.

AIM2 mediated neuron PANoptosis plays an important role in diabetes cognitive dysfunction

The increasing global aging population has led to a rise in diabetic cognitive dysfunction (DCD), a common complication of diabetes that significantly impacts the health of elderly individuals. Neuronal death is a key factor in cognitive impairment, with studies showing interactions between cellular pyroptosis, apoptosis, and necroptosis in the development of neurodegenerative disorders. This has led to the concept of PANoptosis, where these pathways work together to cause cell death. High glucose levels can induce neuronal damage and cognitive dysfunction in rats, leading to various forms of programmed cell death. It is hypothesized that high glucose can trigger neuronal PANoptosis, resulting in cognitive dysfunction. AIM2, an upstream regulator of PANoptosis, is closely associated with the pathogenesis of DCD. In DCD, dysregulated glucose metabolism induces the release of mitochondrial DNA (mtDNA), which acts as a ligand to activate the cell membrane-bound DNA sensor AIM2. Upon activation, AIM2 oligomerizes and recruits a caspase recruit domain (ASC), forming a complex that activates caspase-1. Caspase-1 activation subsequently triggers the production of pro-inflammatory cytokines, induces pyroptosis, and mediates apoptosis, necroptosis, and PANoptosis in neurons through signaling crosstalk. Understanding the pathophysiological mechanism of AIM2-mediated neuronal PANoptosis in DCD development can aid in early diagnosis and identify new therapeutic targets.

Prognostic value of glycemic gap in ST-segment elevation myocardial infarction-associated acute kidney injury

BACKGROUND

Stress-induced hyperglycemia (SIH) is a common phenomenon in acute myocardial infarction and is associated with poor prognosis. The relationship between glycemic gap (GG), a marker of SIH, and ST-segment elevation myocardial infarction (STEMI)-associated acute kidney injury (STAAKI) remains unclear. This study aims to explore the predictive value of GG for the risk of STAAKI after percutaneous coronary intervention (PCI) in STEMI patients.

METHODS

This study retrospectively selected patients diagnosed with STEMI who underwent primary PCI. Logistic regression analysis was used to identify the risk factors associated with STAAKI. To examine the dose-response relationship between GG and STAAKI, restricted cubic splines (RCS) were employed. The predictive accuracy of the models was assessed using Delong test, net reclassification index (NRI) and integrated discrimination improvement (IDI).

RESULTS

This study included 595 patients, the incidence of STAAKI was 9.2%. Multivariate logistic regression showed LVEF (OR per 1% increase = 0.931, 95% CI: 0.895 ~ 0.969), NT-proBNP (OR per 1 pg/mL increase = 1.579, 95% CI: 1.212 ~ 2.057), and GG (OR per 1 mmol/L increase = 1.379, 95% CI: 1.223 ~ 1.554) as independent predictors of STAAKI. RCS analysis indicated a linear dose-response relationship between GG and STAAKI. After integrating GG, the new model could significantly improve the risk model for STAAKI (Z = 2.77, NRI = 0.780, and IDI = 0.095; All P < 0.05).

CONCLUSION

GG is an independent risk factor for the occurrence of STAAKI after PCI in STEMI patients, and integrating GG can significantly improve risk modeling regarding STAAKI.

CLINICAL TRIAL NUMBER

Not applicable.

Assessing Practice Variation of Anesthetic Management for Endovascular Thrombectomy in Acute Ischemic Stroke: A Comprehensive Multicenter Survey

OBJECTIVE

This study explored the current global landscape of periprocedural care of acute ischemic stroke patients undergoing endovascular thrombectomy (EVT).

METHODS

An anonymous, 54-question electronic survey was sent to 354 recipients in hospitals worldwide. The responses were stratified by World Bank country income level into high-income (HICs) and low/middle-income (LMICs) countries.

RESULTS

A total of 354 survey invitations were issued. Two hundred twenty-three respondents started the survey, and 87 fully completed surveys were obtained from centers in which anesthesiologists were routinely involved in EVT care (38 in HICs; 49 in LMICs). Respondents from 35 (92.1%) HICs and 14 (28.6%) LMICs reported that their centers performed >50 EVTs annually. Respondents from both HICs and LMICs reported low rates of anesthesiologist involvement in pre-EVT care, though a communication system was in place in 100% of HIC centers and 85.7% of LMIC centers to inform anesthesiologists about potential EVTs. Respondents from 71.1% of HIC centers and 51% of LMIC centers reported following a published guideline during EVT management, though the use of cognitive aids was low in both (28.9% and 24.5% in HICs and LMICs, respectively). Variability in multiple areas of practice, including choice of anesthetic techniques, monitoring and management of physiological variables during EVT, and monitoring during intrahospital transport, were reported. Quality metrics were rarely tracked or reported to the anesthesiology teams.

CONCLUSIONS

This study demonstrated variability in anesthesiology involvement and in clinical care during and after EVT. Centers may consider routinely involving anesthesiologists in pre-EVT care, using evidence-based recommendations for EVT management, and tracking adherence to published guidelines and other quality metrics.

Construction of predictive model for the risk of acute lactic acidosis in patients with ischemic stroke during the ICU stay: A study based on the medical information Mart for intensive care database

BACKGROUND

This study aims to identify the factors influencing the risk of lactic acidosis (LA) in patients with ischemic stroke (IS) and to develop a predictive model for assessing the risk of LA in IS patients during their stay in the intensive care unit (ICU).

METHODS

A retrospective cohort design was employed, with data collected from the Medical Information Mart for Intensive Care (MIMIC)-III and MIMIC-IV databases spanning from 2001 to 2019. LA was defined as pH < 7.35 and lactate ≥ 2 mmol/L. The total sample was randomly divided into a training set and a testing set at a 7:3 ratio. Predictive variables were selected using bidirectional stepwise regression to build the final model. Model performance was evaluated using receiver operating characteristic (ROC) curves, calibration curves, and decision curves.

RESULTS

The study included 531 patients, of whom 50 (13.47 %) developed LA. The predictive factors included in the model were hypertension, weight, heart rate, Charlson comorbidity index (CCI), Sequential Organ Failure Assessment (SOFA) score, white blood cell (WBC) count, insulin use, sodium bicarbonate administration, and renal replacement therapy (RRT).. The model demonstrated an area under the ROC curve (AUC) of 0.785 [95 % confidence interval (CI): 0.717-0.854] for the training dataset, and 0.721 (95 % CI: 0.615-0.826) for the testing dataset.

CONCLUSION

The predictive model developed for assessing the risk of LA in IS patients demonstrates encouraging predictive performance. It can play a crucial role in managing acid-base balance during ICU stays and assist in the prevention and management of LA in these patients.

Impact of glycemic treatment and blood glucose monitoring on outcomes in patients with acute ischemic stroke without prior diabetes: a longitudinal cohort study

OBJECTIVES

To explore the short- and long-term effects of glycemic management-through glycemic treatment and blood glucose monitoring (BGM)-on stroke recurrence and mortality specifically in patients experiencing a first-ever ischemic stroke (FIS) with hyperglycemia (FISHG) who have not previously been diagnosed with diabetes mellitus (DM).

METHODS

We gathered data on patients who were registered on Taiwan's National Health Insurance Research Database from 2000 to 2015. We one-fold propensity-score-matched (by sex, age, and index date) 207,054 patients into 3 cohorts: those with FIS (1) without hyperglycemia, (2) hyperglycemia without glycemic treatment, and (3) hyperglycemia with glycemic treatment. We used Cox proportional hazard regression to evaluate the short- (within 1 year after FIS) and long-term (9.3 ± 8.6 years after FIS) prognostic effects of glycemic management on stroke recurrence and mortality of FISHG.

RESULTS

Stroke recurrence and mortality were significantly more likely in the patients with FISHG than their counterparts without hyperglycemia (p < 0.05). Under glycemic treatment, patients with FISHG demonstrated lower risk of mortality at every follow-up than those without (p < 0.001) but were not less likely to have stroke recurrence (p > 0.05). Integrating BGM with glycemic treatment in the FISHG cohort significantly reduced the risk of stroke recurrence compared to patients receiving only glycemic treatment at 1-month, 3-month, 6-month, and 1-year post-stroke follow-ups (adjusted hazard ratios = 0.84, 0.90, 0.88, and 0.92, respectively); additionally, this approach significantly decreased mortality risk at each post-stroke follow-up period (p < 0.05).

CONCLUSIONS

BGM combined with glycemic treatment significantly improves prognosis in patients with FISHG who have not been previously diagnosed with DM, reducing the risks of stroke recurrence and mortality.

Neuroprotective Potential of Nitroglycerin in Ischemic Stroke: Insights into Neural Glucose Metabolism and Endoplasmic Reticulum Stress Inhibition

BACKGROUND

Glyceryl trinitrate (GTN), also known as nitroglycerin, is predominantly recognized as a vasodilator for ischemic heart disease, and its potential neuroprotective properties in acute ischemic stroke remain under exploration. We sought to discover the therapeutic advantages and mechanisms of post-recanalization GTN administration in acute ischemic stroke.

METHODS AND RESULTS

A total of 118 male Sprague-Dawley rats were divided into groups: sham, transient/permanent middle cerebral artery occlusion (MCAO) with or without GTN treatment, and transient/permanent MCAO treated with both GTN and KT5823, an inhibitor of PKG. Acute ischemic stroke was induced by transient MCAO for 2 hours followed by 6 or 24 hours of reperfusion and permanent MCAO (28-hour MCAO without reperfusion). The study assessed infarct volumes, neurological deficits, glucose metabolism metrics, NO, and cGMP levels via ELISA. mRNA and protein expression of key molecules of hyperglycolysis, gluconeogenesis, endoplasmic reticulum stress as well as signaling molecules (PKG, AMPK) were conducted via reverse transcription polymerase chain reaction and Western blotting, and cell death was assessed with TUNEL and ELISA. GTN significantly reduced cerebral infarct volumes, neurological deficits, and cell death only after transient MCAO. GTN led to a significant reduction in the expression of NO and cGMP levels, key glucose metabolism, endoplasmic reticulum stress-related genes and proteins, and phosphorylated AMPK while boosting PKG expression, in transient MCAO but not permanent MCAO. The GTN-induced reduction in glucose metabolites, lactate, and reactive oxygen species was exclusive to transient MCAO groups. Coadministration of GTN and PKG inhibitors reversed the observed GTN benefits.

CONCLUSIONS

GTN induced neuroprotection in transient MCAO by improving glucose metabolism and potentially controlling endoplasmic reticulum stress through the NO-cGMP-PKG signaling cascade to inhibit AMPK phosphorylation.

Elucidating the role of physical exercises in alleviating stroke-associated homeostatic dysregulation: a systematic review and meta-analysis

Background

This study aimed to investigate the role of physical exercises as a non-pharmacological intervention for ameliorating post-stroke dysregulated homeostatic parameters.

Methods

Embase, PubMed, PEDro, ISI Web of Science and CENTRAL were searched until April 2024. Parallel randomised controlled trials (RCTs) analysing the effect of post-stroke physical exercises (PSPE) on homeostatic parameters such as blood glucose, oxygen consumption (VO2), high-density lipoprotein (HDL), low-density lipoprotein (LDL), systolic (SBP) and diastolic blood pressure (DBP) in individuals with stroke were selected.

Results

Sixteen RCTs (n=698) were included. PSPE reduced fasting glucose levels (MD=-0.22; 95% CI -0.22 to -0.02; p=0.00) and increased the VO2 (MD=2.51; 95% CI 1.65 to 3.37; p=0.00) and blood HDL levels (MD=0.07; 95% CI 0.00 to 0.13; p=0.00). However, we did not observe beneficial effects on LDL, SBP and DBP parameters. Further analyses demonstrated that both low and moderate exercises are more suitable for improving blood glucose and VO2 in this population.

Discussion

PSPE have the potential to improve dysregulated post-stroke parameters by reducing blood glucose levels and increasing VO2 and HDL levels. However, the small size and limited number of included studies limited the precision of our results. Further research is needed to comprehensively analyse the effects of PSPE, particularly on LDL levels and blood pressure.

PROSPERO registration number

CRD42023395715.

Apolipoprotein E deficiency exacerbates blood-brain barrier disruption and hyperglycemia-associated hemorrhagic transformation after ischemic stroke

BACKGROUND

The polymorphism of the apolipoprotein E (ApoE) gene has been implicated in both the susceptibility to neurodegenerative disease and the prognosis of traumatic brain injury (TBI). However, the influence of ApoE on the risk of hemorrhagic transformation (HT) after acute ischemic stroke remains inconclusive. The present study aimed to investigate the potential impact of ApoE deficiency on the risk of hyperglycemia-associated HT and to elucidate the underlying mechanisms.

METHODS

Wild-type (WT) and ApoE knockout (ApoE-/-) mice were injected with 50 % glucose to induce hyperglycemia and subsequently subjected to 90 min of intraluminal middle cerebral artery occlusion (MCAO). The mortality, neurological function, HT incidence and HT grading-score were evaluated at 24 hours after reperfusion. To evaluate the integrity of blood-brain barrier (BBB), the immunoglobulin G (IgG) leakage and the protein expressions of tight junctions (TJs) were detected using immunofluorescent staining and western blotting. Finally, the levels of matrix metalloproteinases (MMP)-2/9, microglial activation and proinflammatory mediators were investigated using immunofluorescent staining and western blotting.

RESULTS

ApoE-/- mice exhibited increased mortality and exacerbated neurological impairment, concomitant with more severe hyperglycemia-associated HT 24 hours post-reperfusion. Meanwhile, ApoE deficiency exacerbated the disruption of BBB, characterized by increased leakage of IgG, aggravated degradation of TJs and microvascular basement membranes. Furthermore, ApoE deficiency further aggravated the upregulation of MMP-2/9 and microglia-triggered neuroinflammation.

CONCLUSIONS

Our findings demonstrate that the absence of ApoE exacerbates neurological impairment and hyperglycemia-associated HT in ischemic stroke mice, which is closely associated with MMP-2/9 signaling and neuroinflammation-mediated disruption of BBB.

Glucose Fluctuations in Acute Ischemic Stroke

INTRODUCTION

The Oxfordshire Community Stroke Project denotes four subtypes of ischemic stroke (total and partial anterior infarct, posterior, and lacunar). Hyperglycemia has been associated with a larger infarct size and poor prognosis.

AIM

The purpose of the study was to investigate the correlation of glucose fluctuations with the Oxford sub-categories and patient outcomes using a blinded continuous glucose monitoring system.

METHODS

This is a non-interventional prospective observational study. Stroke patients with symptoms onset in the last 24h, participated in the study. A glucose sensor was placed for 72 hours. Disability was assessed using the modified Rankin Scale. Stroke subtypes were compared with total mean glucose and time in range using ANOVA analysis. Multiple ordinal logistic regression was employed to analyze outcomes and survival.

RESULTS

The sample consisted of 105 diabetic and non-diabetic patients. The overall mean glucose was 127.06 mg/dL and the time in range (70-140 mg/dL) was 70.98%. There was no significant difference between the stroke sub-categories and the total mean glucose. For every one-point increase in the time in range, we expect a 1.5% reduction in the odds of having a worse outcome. Patients with total anterior infarct are 2.31 times more likely to have a worse outcome than lacunar patients.

CONCLUSION

The utilization of the Oxford classification may not be necessary for managing acute ischemic stroke glucose levels. Achieving glucose regulation and an increase in time in range can be attained through meticulous control, potentially extending life expectancy. Continuous glucose monitors may aid in achieving this objective.

Stress hyperglycemia and risk of adverse outcomes in patients with acute ischemic stroke: a systematic review and dose-response meta-analysis of cohort studies

Background

Stroke represents a prominent global health issue, exhibiting the third highest incidence of disability and a significant burden on both healthcare and the economy. Stress hyperglycemia, an acute reaction of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system, leading to adverse outcomes and mortality. Several previous studies have indicated that stress hyperglycemia, as evaluated by the stress hyperglycemia ratio (SHR), significantly increases the risk of adverse outcomes and mortality in stroke patients. However, there is a lack of further investigation into the influence of dynamic changes in stress hyperglycemia on the clinical outcomes of acute ischemic stroke (AIS) patients. Consequently, we performed a meticulous analysis, considering dose-response relationships from existing studies, to ascertain the correlation between dynamic changes in stress hyperglycemia and the susceptibility to adverse outcomes in patients with AIS.

Methods

This investigation was prospectively registered in PROSPERO and adhered to the PRISMA guidelines. A comprehensive search was performed across English and Chinese databases. A two-sided random-effects model was employed to consolidate the odds ratios (ORs) of the highest vs. lowest categories of SHR. Restricted cubic spline (RCS) models were employed to estimate potential non-linear trends between SHR and the risk of adverse outcomes in AIS patients. Egger's test was utilized to assess publication bias. Heterogeneity was evaluated using Cochran's Q-test. The Newcastle-Ottawa Scale (NOS) tool was employed to evaluate the risk of bias of the included studies.

Results

The final analysis incorporated a total of thirteen studies, which were published between 2019 and 2023, encompassing a participant cohort of 184,179 individuals. The SHR exhibited a significant association with the risk of various adverse outcomes. Specifically, a higher SHR was correlated with a 2.64-fold increased risk of 3-month poor functional outcomes (OR: 2.64, 95% CI 2.05-3.41, I2 = 52.3%, P < 0.001), a 3.11-fold increased risk of 3-month mortality (OR: 3.11, 95% CI 2.10-4.59, I2 = 38.6%, P < 0.001), a 2.80-fold increased risk of 1-year mortality (OR: 2.80, 95% CI 1.81-4.31, I2 = 88%, P < 0.001), a 3.90-fold increased risk of intracerebral hemorrhage (ICH) and 4.57-fold increased risk of symptomatic ICH (sICH) (ICH-OR: 3.90, 95% CI 1.52-10.02, I2 = 84.3%, P = 0.005; sICH-OR: 4.57, 95% CI 2.05-10.10, I2 = 47.3%, P < 0.001), a 1.73-fold increased risk of neurological deficits (OR: 1.73, 95 CI 1.44-2.08, I2 = 0%, P < 0.001), and a 2.84-fold increased risk of stroke recurrence (OR: 2.84, 95 CI 1.48-5.45, I2 = 50.3%, P = 0.002). It is noteworthy that, except for hemorrhagic transformation (HT) and stroke recurrence, the remaining adverse outcomes exhibited a "J-shaped" non-linear dose-response relationship.

Conclusion

In summary, our findings collectively suggest that increased exposure to elevated SHR is robustly linked to a heightened risk of adverse outcomes and mortality in individuals with AIS, exhibiting a non-linear dose-response relationship. These results underscore the significance of SHR as a predictive factor for stroke prognosis. Therefore, further investigations are warranted to explore the role of SHR in relation to adverse outcomes in stroke patients from diverse ethnic populations. Furthermore, there is a need to explore the potential benefits of stress hyperglycemia control in alleviating the physical health burdens associated with AIS. Maintaining a lower SHR level may potentially reduce the risk of adverse stroke outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42023424852.

Protective effects of chronic humanin treatment in mice with diabetic encephalopathy: A focus on oxidative stress, inflammation, and apoptosis

Diabetes is known to cause cognitive impairments through various mechanisms, including oxidative stress, inflammation, and apoptosis. Humanin (HN) has been shown to have protective effects on cognitive impairments induced by factors such as Aβ, muscarinic receptor antagonists, and aging in rodents. However, the mechanisms underlying the protective effects of HN in the prefrontal cortex and hippocampus in the context of diabetes are not well understood. In this study, we aimed to investigate the potential protective role of HN on oxidative stress, inflammation, and apoptosis in mice with diabetes. We divided the mice into four groups, including a control group (treated with saline), a humanin group (treated with 4 mg/kg of HN), a streptozotocin (STZ) group (diabetic control), and an STZ+Humanin group. The mice were administered HN daily for 15 days. Our results showed that in the prefrontal cortex and hippocampus of the diabetes group, oxidative stress parameters, pro-inflammatory cytokines, apoptosis and, blood glucose levels were increased, while antioxidant and anti-inflammatory cytokines were diminished compared to the control group. However, HN treatment was able to modulate these markers, including blood glucose and the markers of oxidative stress, inflammation, and apoptosis. In conclusion, our findings suggest that hyperglycemia, oxidative stress, inflammation, and apoptosis may contribute to the development of diabetes-induced cognitive impairments. By regulating these changes with HN treatment, we may be able to positively contribute to the treatment of cognitive impairments induced by diabetes.

Cerebral Glucose Metabolism and Potential Effects on Endoplasmic Reticulum Stress in Stroke

Ischemic stroke is an extremely common pathology with strikingly high morbidity and mortality rates. The endoplasmic reticulum (ER) is the primary organelle responsible for conducting protein synthesis and trafficking as well as preserving intracellular Ca2+ homeostasis. Mounting evidence shows that ER stress contributes to stroke pathophysiology. Moreover, insufficient circulation to the brain after stroke causes suppression of ATP production. Glucose metabolism disorder is an important pathological process after stroke. Here, we discuss the relationship between ER stress and stroke and treatment and intervention of ER stress after stroke. We also discuss the role of glucose metabolism, particularly glycolysis and gluconeogenesis, post-stroke. Based on recent studies, we speculate about the potential relationship and crosstalk between glucose metabolism and ER stress. In conclusion, we describe ER stress, glycolysis, and gluconeogenesis in the context of stroke and explore how the interplay between ER stress and glucose metabolism contributes to the pathophysiology of stroke.

Hepatic responses following acute ischemic stroke: A clinical research update

Acute ischemic stroke (AIS) not only affects the brain but also has significant implications for peripheral organs through neuroendocrine regulation. This reciprocal relationship influences overall brain function and stroke prognosis. Recent research has highlighted the importance of poststroke liver changes in determining patient outcomes. In our previous study, we investigated the relationship between stroke and liver function. Our findings revealed that the prognostic impact of stress-induced hyperglycemia in patients undergoing acute endovascular treatment for acute large vessel occlusion is closely related to their preexisting diabetes status. We found that the liver contributes to stress hyperglycemia after AIS by increasing hepatic gluconeogenesis and decreasing hepatic insulin sensitivity. These changes are detrimental to the brain, particularly in patients without diabetes. Furthermore, we examined the role of bilirubin, a byproduct of hepatic hemoglobin metabolism, in stroke pathophysiology. Our results demonstrated that blood bilirubin levels can serve as predictors of stroke severity and may hold therapeutic potential for reducing oxidative stress-induced stroke injury in patients with mild stroke. These results underscore the potential role of the liver in the oxidative stress response following AIS, paving the way for further investigation into liver-targeted therapeutic strategies to improve stroke prognosis and patient outcomes.

Incidence of Stress-Induced Hyperglycemia in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

The aim of this study was to systematically evaluate the incidence of stress-induced hyperglycemia (SIH) in acute ischemic stroke (AIS). Studies that reported SIH incidence in AIS and examined risk factors for SIH and non-SIH patients were systematically searched in PubMed, Embase, Cochrane Library, and Web of Science from the inception of each database to December 2021. Article screening and data extraction were performed by two independent reviewers according to the inclusion and exclusion criteria. The quality of the included studies was assessed using the Newcastle–Ottawa Scale (NOS), and meta-analysis was performed using Stata. A total of 13 studies involving 4552 patients (977 in the SIH group and 3575 in the non-SIH group) were included. Meta-analysis showed that the incidence of SIH was 24% (95% CI: 21–27%) in the total population, 33% (14–52%) in North America, 25% (20–29%) in Europe, and 21% (12–29%) in Asia. Subgroup analysis by year of publication revealed that the pooled incidence of SIH was 27% (22–32%) in studies published before 2010 and 19% (14–24%) in those published after 2010. SIH is relatively common in AIS and poses a serious public health problem. Therefore, more emphasis should be placed on the prevention and control of SIH in AIS.

Large vessel occlusion stroke outcomes in diabetic vs. non-diabetic patients with acute stress hyperglycemia

OBJECTIVE

This study assesses whether stress-induced hyperglycemia is a predictor of poor outcome at 3 months for patients with acute ischemic stroke (AIS) treated by endovascular treatment (EVT) and impacted by their previous blood glucose status.

METHODS

This retrospective study collected data from 576 patients with AIS due to large vessel occlusion (LVO) treated by EVT from March 2019 to June 2022. The sample was composed of 230 and 346 patients with and without diabetes mellitus (DM), respectively, based on their premorbid diabetic status. Prognosis was assessed with modified Rankin Scale (mRS) at 3-month after AIS. Poor prognosis was defined as mRS>2. Stress-induced hyperglycemia was assessed by fasting glucose-to-glycated hemoglobin ratio (GAR). Each group was stratified into four groups by quartiles of GAR (Q1-Q4). Binary logistic regression analysis was used to identify relationship between different GAR quartiles and clinical outcome after EVT.

RESULTS

In DM group, a poor prognosis was seen in 122 (53%) patients and GAR level was 1.27 ± 0.44. These variables were higher than non-DM group and the differences were statistically significant (p < 0.05, respectively). Patients with severe stress-induced hyperglycemia demonstrated greater incidence of 3-month poor prognosis (DM: Q1, 39.7%; Q2, 45.6%; Q3, 58.6%; Q4, 68.4%; p = 0.009. Non-DM: Q1, 31%; Q2, 32.6%; Q3, 42.5%; Q4, 64%; p < 0.001). However, the highest quartile of GAR was independently associated with poor prognosis at 3 months (OR 3.39, 95% CI 1.66-6.96, p = 0.001), compared to the lowest quartile in non-DM patients after logistic regression. This association was not observed from DM patients.

CONCLUSION

The outcome of patients with acute LVO stroke treated with EVT appears to be influenced by premorbid diabetes status. However, the poor prognosis at 3-month in patients with DM is not independently correlated with stress-induced hyperglycemia. This could be due to the long-term damage of persistent hyperglycemia and diabetic patients' adaptive response to stress following acute ischemic damage to the brain.

Prognostic significance of diabetes and stress hyperglycemia in acute stroke patients

BACKGROUND

Hyperglycemic non-diabetic stroke patients have a worse prognosis than both normoglycemic and diabetic patients. Aim of this study was to assess whether hyperglycemia is an aggravating factor or just an epiphenomenon of most severe strokes.

METHODS

In this retrospective study, 1219 ischemic or hemorrhagic stroke patients (73.7 ± 13.1 years) were divided into 4 groups: 0 = non-hyperglycemic non-diabetic, 1 = hyperglycemic non-diabetic, 2 = non-hyperglycemic diabetic and 3 = hyperglycemic diabetic. Hyperglycemia was defined as fasting blood glucose ≥ 126 mg/dl (≥ 7 mmol/l) measured the morning after admission, while the diagnosis of diabetes was based on a history of diabetes mellitus or on a glycated hemoglobin ≥ 6.5% (≥ 48 mmol/mol), independently of blood glucose levels. All diabetic patients, except 3, had Type 2 diabetes. The 4 groups were compared according to clinical history, stroke severity indicators, acute phase markers and main short term stroke outcomes (modified Rankin scale ≥ 3, death, cerebral edema, hemorrhagic transformation of ischemic lesions, fever, oxygen administration, pneumonia, sepsis, urinary infection and heart failure).

RESULTS

Group 1 patients had more severe strokes, with larger cerebral lesions and higher inflammatory markers, compared to the other groups. They also had a high prevalence of atrial fibrillation, prediabetes, previous stroke and previous arterial revascularizations. In this group, the highest frequencies of cerebral edema, hemorrhagic transformation, pneumonia and oxygen administration were obtained. The prevalence of dependency at discharge and in-hospital mortality were equally high in Group 1 and Group 3. However, in multivariate analyses including stroke severity, cerebral lesion diameter, leukocytes and C-reactive protein, Group 1 was only independently associated with hemorrhagic transformation (OR 2.01, 95% CI 0.99-4.07), while Group 3 was independently associated with mortality (OR 2.19, 95% CI 1.32-3.64) and disability (OR 1.70, 95% CI 1.01-2.88).

CONCLUSIONS

Hyperglycemic non-diabetic stroke patients had a worse prognosis than non-hyperglycemic or diabetic patients, but this group was not independently associated with mortality or disability when size, severity and inflammatory component of the stroke were accounted for.

Systemic inflammation after stroke: implications for post-stroke comorbidities

Immunological mechanisms have come into the focus of current translational stroke research, and the modulation of neuroinflammatory pathways has been identified as a promising therapeutic approach to protect the ischemic brain. However, stroke not only induces a local neuroinflammatory response but also has a profound impact on systemic immunity. In this review, we will summarize the consequences of ischemic stroke on systemic immunity at all stages of the disease, from onset to long‐term outcome, and discuss underlying mechanisms of systemic brain‐immune communication. Furthermore, since stroke commonly occurs in patients with multiple comorbidities, we will also overview the current understanding of the potential role of systemic immunity in common stroke‐related comorbidities, such as cardiac dysfunction, atherosclerosis, diabetes, and infections. Finally, we will highlight how targeting systemic immunity after stroke could improve long‐term outcomes and alleviate comorbidities of stroke patients.

Endovascular Thrombectomy Reduces Risk of Poor Functional Outcomes in Patients Presenting within 0-6 Hours with Large Ischemic Core Volumes on Computed Tomography Perfusion

INTRODUCTION

Patients presenting with large ischemic core volumes (LICVs) on computed tomography perfusion (CTP) are at high risk for poor functional outcomes. We sought to identify predictors of outcome in patients with an internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion and LICV.

METHODS

A large healthcare system's prospectively collected code stroke registry was utilized for this retrospective analysis of patients presenting within 6 hours with at least 50 ml of CTP reduced relative cerebral blood flow (CBF) < 30%. A multivariable logistic regression model was constructed to identify independent predictors (p < 0.05) of poor discharge outcome (modified Rankin scale score 4-6).

RESULTS

Over a 38-month period, we identified 104 patients meeting inclusion criteria, with a mean age of 65.4 ± 16.2 years, median presenting National Institutes of Health Stroke Scale score 20 (IQR 16-24), median ischemic core volume (CBF < 30%) 82 ml (IQR 61-118), and median mismatch volume 80 ml (IQR 56-134). Seventy-five patients (72.1%) had a discharge modified Rankin scale score of 4-6. Sixty-six of 104 (63.5%) patients were treated with endovascular thrombectomy (EVT). In the multivariable regression model, EVT (OR 0.303; 95% CI 0.080-0.985; p = 0.049) and lower blood glucose (per 1-point increase, OR 1.014; 95% CI 1.003-1.030; p = 0.030) were independently protective against poor discharge outcome.

CONCLUSIONS

EVT is independently associated with a reduced risk of poor functional outcome in patients presenting within 6 hours with ICA or MCA occlusions and LICV.

Efficacy of Biologically Active Food Supplements for People with Atherosclerotic Vascular Changes

The current paper deals with the development of a new biologically active food supplement (BAFS) aimed at treating atherosclerosis. Since atherosclerosis is considered to be a disease of aging, the composition of the supplement includes such essential minerals as magnesium and potassium, which are commonly used to prevent atherosclerosis, as well as vitamins C, E and the B-group vitamins in order to address the needs of the elderly. The authors outline the supplement-manufacturing technology and discuss the clinical trial undertaken by patients, aged about 60 years, with peripheral atherosclerosis. The research methodology focuses on studying the effectiveness of the developed supplement by assessing the influence of the active ingredients on treating metabolic disorders. To establish the efficacy of the supplement, blood tests, ultrasound and physical examinations were applied. The combination therapy resulted in improved metabolism and an overall better performance of the cardiovascular system; therefore, the BASF can be recommended as part of combination therapy to prevent and treat atherosclerotic and age-related changes in blood vessels.

Neuroprotective Effects of Pharmacological Hypothermia on Hyperglycolysis and Gluconeogenesis in Rats after Ischemic Stroke

Stroke is a leading threat to human life. Metabolic dysfunction of glucose may play a key role in stroke pathophysiology. Pharmacological hypothermia (PH) is a potential neuroprotective strategy for stroke, in which the temperature is decreased safely. The present study determined whether neuroprotective PH with chlorpromazine and promethazine (C + P), plus dihydrocapsaicin (DHC) improved glucose metabolism in acute ischemic stroke. A total of 208 adult male Sprague Dawley rats were randomly divided into the following groups: sham, stroke, and stroke with various treatments including C + P, DHC, C + P + DHC, phloretin (glucose transporter (GLUT)-1 inhibitor), cytochalasin B (GLUT-3 inhibitor), TZD (thiazolidinedione, phosphoenolpyruvate carboxykinase (PCK) inhibitor), and apocynin (nicotinamide adenine dinucleotide phosphate oxidase (NOX) inhibitor). Stroke was induced by middle cerebral artery occlusion (MCAO) for 2 h followed by 6 or 24 h of reperfusion. Rectal temperature was monitored before, during, and after PH. Infarct volume and neurological deficits were measured to assess the neuroprotective effects. Reactive oxygen species (ROS), NOX activity, lactate, apoptotic cell death, glucose, and ATP levels were measured. Protein expression of GLUT-1, GLUT-3, phosphofructokinase (PFK), lactate dehydrogenase (LDH), PCK1, PCK2, and NOX subunit gp91 was measured with Western blotting. PH with a combination of C + P and DHC induced faster, longer, and deeper hypothermia, as compared to each alone. PH significantly improved every measured outcome as compared to stroke and monotherapy. PH reduced brain infarction, neurological deficits, protein levels of glycolytic enzymes (GLUT-1, GLUT-3, PFK and LDH), gluconeogenic enzymes (PCK1 and PCK2), NOX activity and its subunit gp91, ROS, apoptotic cell death, glucose, and lactate, while raising ATP levels. In conclusion, stroke impaired glucose metabolism by enhancing hyperglycolysis and gluconeogenesis, which led to ischemic injury, all of which were reversed by PH induced by a combination of C + P and DHC.

Early Edema Within the Ischemic Core Is Time-Dependent and Associated With Functional Outcomes of Acute Ischemic Stroke Patients

Objective

To investigate the difference in early edema, quantified by net water uptake (NWU) based on computed tomography (CT) between ischemic core and penumbra and to explore predictors of NWU and test its predictive power for clinical outcome.

Methods

Retrospective analysis was conducted on patients admitted to Ningbo First Hospital with anterior circulation stroke and multi-modal CT. In 154 included patients, NWU of the ischemic core and penumbra were calculated and compared by Mann–Whitney U test. Correlations between NWU and variables including age, infarct time (time from symptom onset to imaging), volume of ischemic core, collateral status, and National Institutes of Health Stroke Scale (NIHSS) scores were investigated by Spearman's correlation analyses. Clinical outcome was defined using the modified Rankin Scale (mRS) at 90 days. Logistic regression and receiver operating characteristic analyses were performed to test the predictive value of NWU. Summary statistics are presented as median (interquartile range), mean (standard deviation) or estimates (95% confidence interval).

Results

The NWU within the ischemic core [6.1% (2.9–9.2%)] was significantly higher than that of the penumbra [1.8% (−0.8–4.0%)]. The only significant predictor of NWU within the ischemic core was infarct time (p = 0.004). The NWU within the ischemic core [odds ratio = 1.23 (1.10–1.39)], the volume of ischemic core [1.04, (1.02–1.06)], age [1.09 (1.01–1.17)], and admission NHISS score [1.05 (1.01–1.09)] were associated with the outcome of patients adjusted for sex and treatment. The predictive power for the outcome of the model was significantly higher when NWU was included (area under the curve 0.875 vs. 0.813, p &lt; 0.05 by Delong test).

Conclusions

Early edema quantified by NWU is relatively limited in the ischemic core and develops in a time-dependent manner. NWU estimates within the ischemic core may help to predict clinical outcomes of patients with acute ischemic stroke.

Neuroprotective Mechanisms of Glucagon-Like Peptide-1-Based Therapies in Ischemic Stroke: An Update Based on Preclinical Research

The public and social health burdens of ischemic stroke have been increasing worldwide. Hyperglycemia leads to a greater risk of stroke. This increased risk is commonly seen among patients with diabetes and is in connection with worsened clinical conditions and higher mortality in patients with acute ischemic stroke (AIS). Therapy for stroke focuses mainly on restoring cerebral blood flow (CBF) and ameliorating neurological impairment caused by stroke. Although choices of stroke treatment remain limited, much advance have been achieved in assisting patients in recovering from ischemic stroke, along with progress of recanalization therapy through pharmacological and mechanical thrombolysis. However, it is still necessary to develop neuroprotective therapies for AIS to protect the brain against injury before and during reperfusion, prolong the time window for intervention, and consequently improve neurological prognosis. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are broadly regarded as effective drugs in the treatment of type 2 diabetes mellitus (T2DM). Preclinical data on GLP-1 and GLP-1 RAs have displayed an impressive neuroprotective efficacy in stroke, Parkinson's disease (PD), Alzheimer's disease (AD), Amyotrophic lateral sclerosis (ALS), and other neurodegenerative diseases. Based on the preclinical studies in the past decade, we review recent progress in the biological roles of GLP-1 and GLP-1 RAs in ischemic stroke. Emphasis will be placed on their neuroprotective effects in experimental models of cerebral ischemia stroke at cellular and molecular levels.

Role of Forkhead Box Protein O1 (FoxO1) in Stroke: A Literature Review

Stroke is one of the most prevalent causes of death around the world. When a stroke occurs, many cellular signaling cascades and regulators are activated, which results in severe cellular dysfunction and debilitating long-term disability. One crucial regulator of cell fate and function is mammalian Forkhead box protein O1 (FoxO1). Many studies have found FoxO1 to be implicated in many cellular processes, including regulating gluconeogenesis and glycogenolysis. During a stroke, modifications of FoxO1 have been linked to a variety of functions, such as inducing cell death and inflammation, inhibiting oxidative injury, affecting the blood brain barrier (BBB), and regulating hepatic gluconeogenesis. For these functions of FoxO1, different measures and treatments were applied to FoxO1 after ischemia. However, the subtle mechanisms of post-transcriptional modification and the role of FoxO1 are still elusive and even contradictory in the development of stroke. The determination of these mechanisms will lead to further enlightenment for FoxO1 signal transduction and the identification of targeted drugs. The regulation and function of FoxO1 may provide an important way for the prevention and treatment of diseases. Overall, the functions of FoxO1 are multifactorial, and this paper will summarize all of the significant pathways in which FoxO1 plays an important role during stroke damage and recovery.

Perspectives on benefit of early and prereperfusion hypothermia by pharmacological approach in stroke

Stroke kills or disables approximately 15 million people worldwide each year. It is the leading cause of brain injury, resulting in persistent neurological deficits and profound physical handicaps. In spite of over 100 clinical trials, stroke treatment modalities are limited in applicability and efficacy, and therefore, identification of new therapeutic modalities is required to combat this growing problem. Poststroke oxidative damage and lactic acidosis are widely-recognized forms of brain ischemia/reperfusion injury. However, treatments directed at these injury mechanisms have not been effective. In this review, we offer a novel approach combining these well-established damage mechanisms with new insights into brain glucose handling. Specifically, emerging evidence of brain gluconeogenesis provides a missing link for understanding oxidative injury and lactate toxicity after ischemia. Therefore, dysfunctional gluconeogenesis may substantially contribute to oxidative and lactate damage. We further review that hypothermia initiated early in ischemia and before reperfusion may ameliorate gluconeogenic dysfunction and subsequently provide an important mechanism of hypothermic protection. We will focus on the efficacy of pharmacologically assisted hypothermia and suggest a combination that minimizes side effects. Together, this study will advance our knowledge of basic mechanisms of ischemic damage and apply this knowledge to develop new therapeutic strategies that are desperately needed in the clinical treatment of stroke.

Neuroprotective substances: are they able to protect the pancreatic beta-cells too?

BACKGROUND

Growing evidences demonstrate a close relationship between type 2 diabetes (T2D) and neurodegenerative disorders such as Alzheimer's disease. The similarity of physiological and pathological processes, occurring in pancreatic β-cells and neurons over the course of these pathologies, allows to raise the question of the practicability of studying neuroprotective substances for their potential antidiabetic activity.

OBJECTIVE

This review analyzes studies of antidiabetic and cytoprotective action on pancreatic β-cells of the neuroprotective compounds that can attenuate the oxidative stress and enhance the expression of neurotrophins: low-molecular-weight NGF mimetic compound GK-2, selective anxiolytic afobazole, antidepressants lithium chloride and lithium carbonate on the rat streptozotocin model of T2D.

RESULTS

It was found that all above-listed neuroprotective substances have a pronounced antidiabetic activity. The decrease in the β-cells number, the average area of the pancreatic islets, as well as the violation of their morphological structure caused by the streptozotocin was significantly weakened by the therapy with the investigated neuroprotective substances. The extent of these morphological changes clearly correlates with the antihyperglycemic effect of these compounds.

CONCLUSION

The presented data indicate that the neuroprotective substances attenuating the damaging effect of oxidative stress and neurotrophins deficit cannot only protect neurons but also exert their cytoprotective effect towards pancreatic β-cells. These data may provide a theoretical basis for the further study of neuroprotective drugs as potential therapeutic options for T2D prevention and treatment.

Glucagon-Like Peptide 1 Receptor Agonists – Potential Game Changers in the Treatment of Glaucoma?

Glaucoma is a common ocular neurodegenerative disease characterized by the progressive loss of retinal ganglion cells and their axons. It is the most common cause of irreversible blindness. With an increasing number of glaucoma patients and disease progression despite treatment, it is paramount to develop new and effective therapeutics. Emerging new candidates are the receptor agonists of the incretin hormone glucagon-like-peptide-1 (GLP-1), originally used for the treatment of diabetes. GLP-1 receptor (GLP-1R) agonists have shown neuroprotective effects in preclinical and clinical studies on neurodegenerative diseases in both the brain (e.g., Alzheimer’s disease, Parkinson’s disease, stroke and diabetic neuropathy) and the eye (e.g., diabetic retinopathy and AMD). However, there are currently very few studies investigating the protective effects of GLP-1R agonists in the treatment of specifically glaucoma. Based on a literature search on PubMed, the Cochrane Library, and ClinicalTrials.gov, this review aims to summarize current clinical literature on GLP-1 receptor agonists in the treatment of neurodegenerative diseases to elucidate their potential in future anti-glaucomatous treatment strategies.

Hyperglycemia in acute ischemic stroke: physiopathological and therapeutic complexity

Diabetes mellitus and associated chronic hyperglycemia enhance the risk of acute ischemic stroke and lead to worsened clinical outcome and increased mortality. However, post-stroke hyperglycemia is also present in a number of non-diabetic patients after acute ischemic stroke, presumably as a stress response. The aim of this review is to summarize the main effects of hyperglycemia when associated to ischemic injury in acute stroke patients, highlighting the clinical and neurological outcomes in these conditions and after the administration of the currently approved pharmacological treatment, i.e. insulin. The disappointing results of the clinical trials on insulin (including the hypoglycemic events) demand a change of strategy based on more focused therapies. Starting from the comprehensive evaluation of the physiopathological alterations occurring in the ischemic brain during hyperglycemic conditions, the effects of various classes of glucose-lowering drugs are reviewed, such as glucose-like peptide-1 receptor agonists, DPP-4 inhibitors and sodium glucose cotransporter 2 inhibitors, in the perspective of overcoming the up-to-date limitations and of evaluating the effectiveness of new potential therapeutic strategies.

Alleviation of Neuronal Cell Death and Memory Deficit with Chungkookjang Made with Bacillus amyloliquefaciens and Bacillus subtilis Potentially through Promoting Gut-Brain Axis in Artery-Occluded Gerbils

Short-term fermented soybeans (chungkookjang) with specific Bacillus (B.) spp. have anti-obesity, antidiabetic, and anti-stroke functions. We examined the hypothesis that the long-term consumption of B. amyloliquefaciens SCGB 1 fermented (CKJ1) and B. subtilis SCDB 291 (CKJ291) chungkookjang can alleviate clinical symptoms and hyperglycemia after ischemic stroke by promoting the gut microbiota-brain axis. We examined this hypothesis in Mongolian male gerbils with stroke symptoms induced by carotid artery occlusion. The artery-occluded gerbils were divided into five groups: no supplementation (Control, Normal-control), 4% cooked soybeans (CSB), CKJ1, or CKJ291 in a high-fat diet for 3 weeks. The carotid arteries of gerbils in the Control, CSB, CKJ1, and CKJ291 groups were occluded for 8 min and they then continued on their assigned diets for an additional 3 weeks. Normal-control gerbils had no artery occlusion. The diets in all groups contained an identical macronutrient composition using starch, casein, soybean oil, and dietary fiber. The CSB, CKJ1, and CKJ291 groups exhibited less neuronal cell death than the Control group, while the CKJ1 group produced the most significant reduction among all groups, as much as 85% of the Normal-control group. CKJ1 and CKJ291 increased the blood flow and removal of blood clots, as determined by Doppler, more than the Control. They also showed more improvement in neurological disorders from ischemic stroke. Their improvement showed a similar tendency as neuronal cell death. CKJ1 treatment improved memory impairment, measured with Y maze and passive avoidance tests, similar to the Normal-control. The gerbils in the Control group had post-stroke hyperglycemia due to decreased insulin sensitivity and β-cell function and mass; the CKJ291, CSB, and CKJ1 treatments protected against glucose disturbance after artery occlusion and were similar to the Normal-control. CKJ1 and CKJ291 also reduced serum tumor necrosis factor-α concentrations and hippocampal interleukin-1β expression levels, compared to the Control. CKJ1 and CKJ291 increased the contents of Lactobacillus, Bacillus, and Akkermansia in the cecum feces, similar to the Normal-control. Picrust2 analysis showed that CKJ1 and CKJ291 increased the propionate and butyrate metabolism and the starch and glucose metabolism but reduced the lipopolysaccharide biosynthesis and fatty acid metabolism compared to the Control. In conclusion, daily CKJ1 and CKJ291 intake prevented neuronal cell death and memory dysfunction from the artery occlusion by increasing blood flow and β-cell survival and reducing post-stroke-hyperglycemia through modulating the gut microbiome composition and metabolites to influence the host metabolism, especially inflammation and insulin resistance, protecting against neuronal cell death and brain dysfunction. CKJ1 had better effects than CKJ291.

Phosphoenolpyruvate carboxykinase in cell metabolism: Roles and mechanisms beyond gluconeogenesis

BACKGROUND

Phosphoenolpyruvate carboxykinase (PCK) has been almost exclusively recognized as a critical enzyme in gluconeogenesis, especially in the liver and kidney. Accumulating evidence has shown that the enhanced activity of PCK leads to increased glucose output and exacerbation of diabetes, whereas the defects of PCK result in lethal hypoglycemia. Genetic mutations or polymorphisms are reported to be related to the onset and progression of diabetes in humans.

SCOPE OF REVIEW

Recent studies revealed that the PCK pathway is more complex than just gluconeogenesis, depending on the health or disease condition. Dysregulation of PCK may contribute to the development of obesity, cardiac hypertrophy, stroke, and cancer. Moreover, a regulatory network with multiple layers, from epigenetic regulation, transcription regulation, to posttranscription regulation, precisely tunes the expression of PCK. Deciphering the molecular basis that regulates PCK may pave the way for developing practical strategies to treat metabolic dysfunction.

MAJOR CONCLUSIONS

In this review, we summarize the metabolic and non-metabolic roles of the PCK enzyme in cells, especially beyond gluconeogenesis. We highlight the distinct functions of PCK isoforms (PCK1 and PCK2), depict a detailed network regulating PCK's expression, and discuss its clinical relevance. We also discuss the therapeutic potential targeting PCK and the future direction that is highly in need to better understand PCK-mediated signaling under diverse conditions.

Therapeutic hypothermia augments the restorative effects of PKC-β and Nox2 inhibition on an in vitro model of human blood-brain barrier

To investigate whether therapeutic hypothermia augments the restorative impact of protein kinase C-β (PKC-β) and Nox2 inhibition on an in vitro model of human blood-brain barrier (BBB). Cells cultured in normoglycaemic (5.5 mM) or hyperglycaemic (25 mM, 6 to 120 h) conditions were treated with therapeutic hypothermia (35 °C) in the absence or presence of a PKC-β inhibitor (LY333531, 0.05 μM) or a Nox2 inhibitor (gp91ds-tat, 50 μM). BBB was established by co-culture of human brain microvascular endothelial cells (HBMECs) with astrocytes (HAs) and pericytes. BBB integrity and function were assessed via transendothelial electrical resistance (TEER) and paracellular flux of sodium fluorescein (NaF, 376 Da). Nox activity (lucigenin assay), superoxide anion production (cytochrome-C reduction assay), cellular proliferative capacity (wound scratch assay) and actin cytoskeletal formation (rhodamine-phalloidin staining) were assessed both in HBMECs and HAs using the specific methodologies indicated in brackets. Therapeutic hypothermia augmented the protective effects of PKC-β or Nox2 inhibition on BBB integrity and function in experimental setting of hyperglycaemia, as evidenced by increases in TEER and concomitant decreases in paracellular flux of NaF. The combinatory approaches were more effective in repairing physical damage exerted on HBMEC and HA monolayers by wound scratch and in decreasing Nox activity and superoxide anion production compared to sole treatment regimen with either agent. Similarly, the combinatory approaches were more effective in suppressing actin stress fibre formation and maintaining normal cytoskeletal structure. Therapeutic hypothermia augments the cerebral barrier-restorative capacity of agents specifically targeting PKC-β or Nox2 pathways.

Three-year mortality in cryptococcal meningitis: Hyperglycemia predict unfavorable outcome

Existing evidence revealed grave prognosis for cryptococcal meningitis (CM), particularly its short-term mortality. However, its long-term survival and prognostic factors remained unknown. This study investigated 3-year mortality and analyzed its predictive factors in patients with CM. This retrospective cohort study with 83 cerebrospinal fluid culture-confirmed CM patients was conducted at China Medical University Hospital from 2003 to 2016. The 3-year mortality rate in patients with CM was 54% (45 deaths among 83 patients). Advanced age, human immunodeficiency virus (HIV) seronegative state, low Glasgow Coma Scale score on admission, decreased hemoglobin and hyperglycemia on diagnosis were associated with 3-year mortality. After multivariate adjustment in the Cox proportional hazard model, only severe hyperglycemia (serum glucose ≥200 mg/dL) on diagnosis could predict 3-year mortality.

Phosphoenolpyruvate Carboxykinase (PCK) in the Brain Gluconeogenic Pathway Contributes to Oxidative and Lactic Injury After Stroke

To demonstrate the role of the rate-limiting and ATP-dependent gluconeogenic enzyme phosphoenolpyruvate carboxykinase (PCK) in oxidative and lactic stress and the effect of phenothiazine on PCK after stroke, a total of 168 adult male Sprague Dawley rats (3 months old, 280-300 g) underwent 2-h intraluminal middle cerebral artery occlusion (MCAO) and reperfusion for 6, 24, 48 h, or 7 days. Phenothiazine (chlorpromazine and promethazine (C+P)) (8 mg/kg) and 3-mercaptopicolinic acid (3-MPA, a PCK inhibitor, 100 μM) were administered at reperfusion onset. The effects of phosphoenolpyruvate, 3-MPA, or PCK knockdown were studied in neuronal cultures subjected to oxygen/glucose deprivation. Reactive oxygen species, lactate, phosphoenolpyruvate (PEP; a gluconeogenic product), mRNA, and protein of total PCK, PCK-1, and PCK-2 increased after MCAO and oxygen-glucose deprivation (OGD). Oxaloacetate (a gluconeogenic substrate) decreased, while PEP and glucose were increased, suggesting reactive gluconeogenesis. These changes were attenuated by phenothiazine, 3-MPA, or PCK shRNA. PCK-1 and -2 existed primarily in neurons, while the effects of ischemic stroke on the PCK expression were seen predominately in astrocytes. Thus, phenothiazine reduced infarction and oxidative/lactic stress by inhibiting PCKs, leading to functional recovery.

Normobaric oxygen therapy attenuates hyperglycolysis in ischemic stroke

Normobaric oxygen therapy has gained attention as a simple and convenient means of achieving neuroprotection against the pathogenic cascade initiated by acute ischemic stroke. The mechanisms underlying the neuroprotective efficacy of normobaric oxygen therapy, however, have not been fully elucidated. It is hypothesized that cerebral hyperglycolysis is involved in the neuroprotection of normobaric oxygen therapy against ischemic stroke. In this study, Sprague-Dawley rats were subjected to either 2-hour middle cerebral artery occlusion followed by 3- or 24-hour reperfusion or to a permanent middle cerebral artery occlusion event. At 2 hours after the onset of ischemia, all rats received either 95% oxygen normobaric oxygen therapy for 3 hours or room air. Compared with room air, normobaric oxygen therapy significantly reduced the infarct volume, neurological deficits, and reactive oxygen species and increased the production of adenosine triphosphate in ischemic rats. These changes were associated with reduced transcriptional and translational levels of the hyperglycolytic enzymes glucose transporter 1 and 3, phosphofructokinase 1, and lactate dehydrogenase. In addition, normobaric oxygen therapy significantly reduced adenosine monophosphate-activated protein kinase mRNA expression and phosphorylated adenosine monophosphate-activated protein kinase protein expression. These findings suggest that normobaric oxygen therapy can reduce hyperglycolysis through modulating the adenosine monophosphate-activated protein kinase signaling pathway and alleviating oxidative injury, thereby exhibiting neuroprotective effects in ischemic stroke. This study was approved by the Institutional Animal Investigation Committee of Capital Medical University (approval No. AEEI-2018-033) on August 13, 2018.

Role of the nurse in the hyperacute care and management of patients following stroke

Stroke is a medical emergency that affects millions of people worldwide each year. The first 24-72 hours following a stroke is a critical stage in the patient's management because deterioration can occur during this period. Hyperacute care is a time-sensitive method of managing stroke that has improved the provision of holistic and evidence-based stroke care. This article describes the care and management that patients require in the first 24-72 hours following stroke. It details the evidence-based practice that this involves, and explains the role of the nurse in providing hyperacute care.

Protective effect of pregabalin on the brain tissue of diabetic rats

Purpose

Diabetes mellitus (DM) is a metabolic disorder characterized by insulin deficiency or insulin resistance. Pregabalin (PGB) is an antiepileptic drug with proven efficacy in the treatment of epilepsy, generalized anxiety disorder, and neuropathic pain. In this study, we aimed to investigate the protective effects of PGB in brain tissue of rats with streptozotocin (STZ)-induced experimental diabetes.

Materials and methods

Twenty-eight Wistar albino male rats were randomly divided into four groups with seven rats each: (I) Control group, (II) PGB (50 mg/kg PBG), (III) DM, and (IV) DM + PGB (50 mg/kg/day PGB per orally for 8 weeks). Diabetes was induced with an intraperitoneal (i.p.) STZ injection (Sigma Chemical Co Louis Missour, USA) at a dose of 180 mg/kg. STZ was dissolved in 0.1 M phosphate-citrate tampon (pH 4.5). Paraffin sections were examined using histological and immunohistochemical analyses. To detect oxidative damage biochemically, malondialdehyde (MDA), the end product of lipid peroxidation; superoxide dismutase (SOD), catalase (CAT), glutathione (GSH) and glutathione peroxidase (GPx) which are antioxidant enzymes, levels were studied. In addition, bax, caspase-3 enzyme activities and TUNEL assay were studied to evaluate the apoptosis status.

Results

In the DM group, MDA concentrations were significantly higher and GPx and SOD activities were significantly lower compared to the control group. MDA concentrations were significantly lower and SOD activity was significantly higher in the DM + PGB group than in the DM group. The GPx activity in the DM group decreased significantly compared to the control group. In immunohistochemical examinations (Bax, Caspase-3 and TUNEL), the apoptosis rate was significantly lower in the in DM + PGB group than in the DM group.

Conclusion

Pregabalin may prevent harmful effects of oxidative damage by decreasing the MDA levels and increasing the SOD levels. In addition, it was thought that PGB may have antiapoptotic properties due to decreased bax and caspase-3 immunoreactivity and TUNEL positivity in PGB groups. Based on these findings, we think that PGB may be effective in reducing the risk of brain damage associated with DM.

Regulation of cytochrome c oxidase contributes to health and optimal life

The generation of cellular energy in the form of ATP occurs mainly in mitochondria by oxidative phosphorylation. Cytochrome c oxidase (CytOx), the oxygen accepting and rate-limiting step of the respiratory chain, regulates the supply of variable ATP demands in cells by “allosteric ATP-inhibition of CytOx.” This mechanism is based on inhibition of oxygen uptake of CytOx at high ATP/ADP ratios and low ferrocytochrome c concentrations in the mitochondrial matrix via cooperative interaction of the two substrate binding sites in dimeric CytOx. The mechanism keeps mitochondrial membrane potential ΔΨ_m and reactive oxygen species (ROS) formation at low healthy values. Stress signals increase cytosolic calcium leading to Ca²⁺-dependent dephosphorylation of CytOx subunit I at the cytosolic side accompanied by switching off the allosteric ATP-inhibition and monomerization of CytOx. This is followed by increase of ΔΨ_m and formation of ROS. A hypothesis is presented suggesting a dynamic change of binding of NDUFA4, originally identified as a subunit of complex I, between monomeric CytOx (active state with high ΔΨ_m, high ROS and low efficiency) and complex I (resting state with low ΔΨ_m, low ROS and high efficiency).

Special bioactive compounds and functional foods may exhibit neuroprotective effects in patients with dementia (Review)

Dementia is a failure of cognitive ability characterized by severe neurodegeneration in select neural systems, and Alzheimer's disease (AD) is the most common type of neurodegenerative disease. Although numerous studies have provided insights into the pathogenesis of AD, the underlying signaling and molecular pathways mediating the progressive decline of cognitive function remain poorly understood. Recent progress in molecular biology has provided an improved understanding of the importance of molecular pathogenesis of AD, and has proposed an association between DNA repair mechanisms and AD. In particular, the fundamental roles of phosphatase and tensin homologue deleted on chromosome 10 (PTEN) and breast cancer gene 1 (BRCA1) tumor suppressors have been shown to regulate the pathogenesis of neurodegeneration. Consequently, onset of neurodegenerative diseases may be deferred with the use of dietary neuroprotective agents which alter the signaling mediated by the aforementioned tumor suppressors. In a healthy neuron, homeostasis of key intracellular molecules is of great importance, and preventing neuronal apoptosis is one of the primary goals of treatments designed for dementia-associated diseases. In the present review, progress into the understanding of dietary regulation for preventing or limiting development of dementia is discussed with a focus on the modulatory roles of PTEN and BRCA1 signaling.

Aliskiren and captopril improve cognitive deficits in poorly controlled STZ-induced diabetic rats via amelioration of the hippocampal P-ERK, GSK3β, P-GSK3β pathway

Learning and memory deficits are obvious symptoms that develop over time in patients with poorly controlled diabetes. Hyperactivity of the renin-angiotensin system (RAS) is directly associated with β-cell dysfunction and diabetic complications, including cognitive impairment. Here, we investigated the protective and molecular effects of two RAS modifiers, aliskiren; renin inhibitor and captopril; angiotensin converting enzyme inhibitor, on cognitive deficits in the rat hippocampus. Injection of low dose streptozotocin for 4 days resulted in type 1 diabetes. Then, poorly controlled diabetes was mimicked with ineffective daily doses of insulin for 4 weeks. The hyperglycaemia and pancreatic atrophy caused memory disturbance that were identifiable in behavioural tests, hippocampal neurodegeneration, and the following significant changes in the hippocampus, increases in the inflammatory marker interleukin 1β, cholinesterase, the oxidative stress marker malondialdehyde and protein expression of phosphorylated extracellular-signal-regulated kinase and glycogen synthase kinase-3 beta versus decrease in the antioxidant reduced glutathione and protein expression of phosphorylated glycogen synthase kinase-3 beta. Blocking RAS with either drugs along with insulin amended all previously mentioned parameters. Aliskiren stabilized the blood glucose level and restored normal pancreatic integrity and hippocampal malondialdehyde level. Aliskiren showed superior protection against the hippocampal degeneration displayed in the earlier behavioural modification in the passive avoidance test, and the aliskiren group outperformed the control group in the novel object recognition test. We therefore conclude that aliskiren and captopril reversed the diabetic state and cognitive deficits in rats with poorly controlled STZ-induced diabetes through reducing oxidative stress and inflammation and modulating protein expression.

Risk of stroke-associated pneumonia during hospitalization: predictive ability of combined A2DS2 score and hyperglycemia

BACKGROUND

Stroke-associated pneumonia (SAP) is a common complication of cerebrovascular disease. The A²DS² score has been used to predict the risk of SAP. However, hyperglycemia is not included in this scale. The purpose of the present study was to explore whether the A²DS² scoring system and hyperglycemia could predict the risk of SAP more effectively than the conventional A²DS² scale.

METHODS

This retrospective study enrolled 2552 patients with acute ischemic stroke. The A²DS² scores, fasting blood glucose level and blood glucose level on admission were collected. Regression analysis was used to identify the independent risk factors of SAP. ROC curve analysis was used to evaluate the specificity and sensitivity of the combined A²DS² score and fasting hyperglycemia for predicting SAP.

RESULTS

Fasting hyperglycemia was an independent risk factor for SAP (OR = 2.95; 95% confidence interval: 2.11-4.12; P < 0.001). The area under curve of the combined A²DS² score and fasting hyperglycemia was significantly higher than that of the A²DS² score alone (0.814 vs. 0.793; P = 0.020).

CONCLUSION

Fasting hyperglycemia is an independent risk factor for predicting SAP. Compared with the A2DS2 score, the modified A2DS2 score (combined A2DS2 score and fasting hyperglycemia) is more effective in predicting the risk of SAP.

Effects of Urinary Kallidinogenase on NIHSS score, mRS score, and fasting glucose levels in acute ischemic stroke patients with abnormal glucose metabolism: A prospective cohort study

Urinary kallidinogenase may assist recovery acute ischemic stroke. This study evaluated the effect of urinary kallidinogenase on National Institute of Health Stroke Scale (NIHSS) score, modified Rankin scale (mRS) score, and fasting glucose levels in patients with acute ischemic stroke (AIS) combined with diabetes mellitus and impaired fasting glucose.Patients with AIS and abnormal glucose metabolism were enrolled in this prospective cohort study and divided into 2 groups. The human urinary kallidinogenase (HUK) group were treated with urinary kallidinogenase and standard treatment; the control group received standard treatment. NIHSS scores, mRS scores, and fasting blood glucose were evaluated and compared.A total of 113 patients were included: 58 in the HUK group and 55 in the control group. NIHSS scores decreased with treatment in both groups (time effect P < .05), but were lower in the HUK group (main effect P = .026). The mRS score decreased in both groups from 10 until 90 days after treatment (time effect P < .05); the 2 groups were similar (main effect, P = .130). Blood glucose levels decreased in both groups 10 days after treatment (time effect, P < .05), but there was no significant treatment effect (main effect, P = .635). Multivariate analysis showed blood uric acid >420 μmol/L (odds ratio [OR]: 0.053, 95% confidence interval [CI]: 0.008-0.350; P = .002) and application of HUK (OR: 0.217, 95% CI: 0.049-0.954; P = .043) were associated with 90% NIHSS recovery. Baseline NIHSS score was independently associated with poor curative effect.Urinary kallidinogenase with conventional therapy significantly improved NIHSS scores in patients with AIS. Urinary kallidinogenase also showed a trend toward lower fasting blood glucose levels, although the level did not reach significance.

Cutting Edge Acute Ischemic Stroke Management

Acute ischemic stroke (AIS) is a medical emergency that requires prompt recognition and streamlined work-up to ensure that time-dependent therapies are initiated to achieve the best outcomes. This article discusses frequently missed AIS in the emergency department, the role of various imagining modalities in the work-up of AIS, updates on the use of intravenous thrombolytics and endovascular therapy for AIS, pearls on supportive care management of AIS, and prehospital and hospital process improvements to shorten door-to-needle time.

Association of serum galectin-3 with risks of death and vascular events in acute ischaemic stroke patients: the role of hyperglycemia

BACKGROUND AND PURPOSE

Whether the association between galectin-3 and stroke outcome is modified by fasting plasma glucose (FPG) is unknown. The aim was to evaluate the prognostic effect of galectin-3 amongst ischaemic stroke patients stratified by FPG.

METHODS

In all, 3082 ischaemic stroke patients were included in this study and serum galectin-3 was tested at baseline. The primary outcome was a composite outcome of death and vascular events, and secondary outcomes were death, stroke recurrence and vascular events within 1 year after stroke.

RESULTS

Increased galectin-3 was significantly associated with the primary outcome, stroke recurrence and vascular events in the patients with hyperglycemia but not in those with normoglycemia (P for interaction < 0.05 for all). The multivariate-adjusted hazard ratios (95% confidence intervals) were 1.72 (1.05-2.84), 2.64 (1.14-6.12) and 2.68 (1.33-5.38) for the primary outcome, stroke recurrence and vascular events, respectively. A linear association between galectin-3 and the primary outcome was observed in hyperglycemic patients (P for linearity = 0.007).

CONCLUSION

Increased galectin-3 was associated with the primary outcome, stroke recurrence and vascular events within 1 year after stroke in the patients with hyperglycemia, suggesting that galectin-3 may be an important prognostic factor for ischaemic stroke patients with hyperglycemia.

Crotalus atrox disintegrin reduces hemorrhagic transformation by attenuating matrix metalloproteinase-9 activity after middle cerebral artery occlusion in hyperglycemic male rats

Hemorrhagic transformation after ischemic stroke is an independent predictor for poor outcome and is characterized by blood vessel rupture leading to brain edema. To date, no therapies for preventing hemorrhagic transformation exist. Disintegrins from the venom of Crotalus atrox have targets within the coagulation cascade, including receptors on platelets. We hypothesized that disintegrins from C. atrox venom can attenuate hemorrhagic transformation by preventing activation of matrix metalloproteinase after middle cerebral artery occlusion (MCAO) in hyperglycemic rats. We subjected 48 male Sprague-Dawley rats weighing 240-260 g to MCAO and hyperglycemia to induce hemorrhagic transformation of the infarction. At reperfusion, we administered either saline (vehicle), whole C. atrox venom (two doses were used), or fractionated C. atrox venom (HPLC Fraction 2). Rats were euthanized 24 hr post-ictus for measurement of infarction and hemoglobin volume. Reversed-phase HPLC was performed to fractionate the whole venom and peaks were combined to form Fraction 2, which contained the disintegrin Crotatroxin. Fraction 2 protected against hemorrhagic transformation after MCAO, and attenuated activation of matrix metalloproteinase-9. Administering matrix metalloproteinase antagonists prevented the protection by Fraction 2. The results of this study indicate that disintegrins found in C. atrox venom may have therapeutic potential for reducing hemorrhagic transformation after ischemic stroke. Moreover, the RP-HPLC fractions retained sufficient protein activity to suggest that gentler and less efficient orthogonal chromatographic methods may be unnecessary to isolate proteins and explore their function.