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

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of mean platelet volume and platelet count on the prognosis of branch atheromatous disease

OBJECTIVE

The purpose of this study was to investigate the predictive value of mean platelet volume (MPV) and platelet count (PC) in branch atheromatous disease (BAD).

METHODS

This retrospective study included 216 patients with BAD-stroke within 48 h of symptom onset. These patients were divided into good and poor prognosis groups according to their 3-month modified Rankin scale scores after discharge. Multiple logistic regression analysis was used to evaluate independent predictors of poor prognosis in BAD-stroke patients. Receiver-operating characteristic (ROC) analysis was used to estimate the predictive value of MPV and PC on BAD-stroke.

RESULTS

Our research showed that a higher MPV (aOR, 2.926; 95% CI, 2.040-4.196; p < .001) and PC (aOR, 1.013; 95% CI, 1.005-1.020; p = .001) were independently associated with poor prognosis after adjustment for confounders. The ROC analysis of MPV for predicting poor prognosis showed that the sensitivity and specificity were 74% and 84.9%, respectively, and that the AUC was .843 (95% CI, .776-.909, p < .001). The optimal cut-off value was 12.35. The incidence of early neurological deterioration (END) was 24.5% (53 of 163), and 66% of patients in the poor prognosis group had END (33 of 50). Multiple logistic regression analyses showed that elevated MPV and PC were associated with the occurrence of END (p < .05).

CONCLUSION

Our results suggested that an elevated MPV and PC may be important in predicting a worse outcome in BAD-stroke patients. Our study also demonstrated an independent association of MPV and PC with END, which is presumably the main reason for the poor prognosis.

Predictive value of admission D-dimer levels in patient with acute ischaemic stroke and COVID-19: a second-wave prospective cohort study

OBJECTIVES

This study aimed to evaluate the predictive value of admission D-dimer levels for in-hospital mortality in patients with COVID-19 and acute ischaemic stroke.

DESIGN

Cohort (prospective).

SETTING

Tertiary referral hospital in the capital city of Indonesia conducted from June to December 2021.

PARTICIPANTS

60 patients with acute ischaemic stroke and COVID-19 were included. Patients were classified into D-dimer groups (low and high) according to a 2 110 ng/mL cut-off value, determined via receiver operating characteristic analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was in-hospital mortality, with admission D-dimer levels as the major predictor. Secondary outcomes included associations between other demographic and clinical variables and the admission D-dimer value. Kaplan-Meier method was used to carry out survival analysis, with univariable and multivariable Cox regression performed to assess the association of D-dimer levels and other confounding variables (including demographic, clinical and laboratory parameters) with in-hospital mortality.

RESULTS

The findings demonstrated an association between elevated admission D-dimer levels (≥2 110 ng/mL) and an increased likelihood of death during hospitalisation. The adjusted HR was 14.054 (95% CI 1.710 to 115.519; p=0.014), demonstrating an increase in mortality risk after accounting for confounders such as age and diabetes history. Other significant predictors of mortality included a history of diabetes and increased white blood cell count.

CONCLUSIONS

Admission D-dimer levels may be a useful predictive indicator for the likelihood of death during hospitalisation in individuals with COVID-19 and acute ischaemic stroke.

Low HALP (Hemoglobin, Albumin, Lymphocyte, and Platelet) Score Increases the Risk of Post-Stroke Cognitive Impairment: A Multicenter Cohort Study

Objective

The HALP (hemoglobin, albumin, lymphocyte, and platelet) score is a novel indicator that measures systemic inflammation and nutritional status that has not been correlated with the risk of post-stroke cognitive impairment in patients with acute ischemic stroke or transient ischemic attack (TIA).

Methods

Study participants were recruited from 40 stroke centers in China. The HALP score was derived using a weighted sum of hemoglobin, albumin, lymphocytes and platelets, and study participants were categorized into 4 groups of equal sizes based on quartiles cutoffs of the HALP score. The Montreal Cognitive Assessment (MoCA)-Beijing Cognitive Assessment Scale (MoCA-Beijing) was performed at 2 weeks and 12 months following stroke onset. Post-stroke cognitive impairment was considered in patients with MoCA-Beijing≤22. Multiple logistic regression methods were employed to evaluate the relationship between the HALP score and the subsequent risk of developing post-stroke cognitive impairment.

Results

The study population comprised 1022 patients (mean age 61.6±11.0 years, 73% men). The proportion of individuals with MoCA-Beijing≤22 at 2 weeks was 49.2% and 32.4% at one year. Patients in the lowest quartile of HALP score (<36.56) were observed to harbor the highest risk of post-stroke cognitive impairment at 12 months post-stroke/TIA compared to those in the highest quartile (odds ratio=1.59, 95% CI=1.07-2.37, p=0.022), and lower domain scores for executive function, naming, and attention. There were no statistically significant differences between patients in the different quartiles of HALP score and HALP score at 2 weeks post-stroke/TIA.

Conclusion

The HALP score is a simple score that could stratify the risk of post-stroke cognitive impairment in stroke/TIA patients to facilitate early diagnosis and interventions.

Hypercoagulability in Sickle Cell Disease: A Thrombo-Inflammatory Mechanism

Sickle cell disease (SCD) is a group of inherited disorders characterized by the presence of abnormal hemoglobin S. Patients with SCD suffer from frequent episodes of anemia, chronic hemolysis, pain crisis, and vaso-occlusion. Additionally, SCD is associated with diverse and serious clinical complications, including thrombosis, which can lead to organ failure, increased morbidity, and eventually, mortality. SCD is known to be a hypercoagulable condition, and the cause of hypercoagulability is multifactorial, with the molecular basis of hemoglobin S being the main driver. The presence of hemoglobin S induces sickling of the RBCs and their subsequent hemolysis, as well as oxidative stress. Both of these processes can alter the hemostatic system, through the activation of platelets, coagulation system, and fibrinolysis, as well as depletion of coagulation inhibitors. These changes can also induce the formation of microvesicles and expression of tissue factor, leading to activation of WBCs, endothelial cell damage, and inflammatory response. Understanding the various factors that drive hypercoagulability as a thrombo-inflammatory mechanism in SCD can help provide explanations for the pathogenesis and other complications of the disease.

Development and verification of a nomogram for predicting short-term mortality in elderly ischemic stroke populations

Stroke is a major healthcare problem worldwide, particularly in the elderly population. Despite limited research on the development of prediction models for mortality in elderly individuals with ischemic stroke, our study aimed to address this knowledge gap. By leveraging data from the Medical Information Mart for Intensive Care IV database, we collected comprehensive raw data pertaining to elderly patients diagnosed with ischemic stroke. Through meticulous screening of clinical variables associated with 28-day mortality, we successfully established a robust nomogram. To assess the performance and clinical utility of our nomogram, various statistical analyses were conducted, including the concordance index, integrated discrimination improvement (IDI), net reclassification index (NRI), calibration curves and decision curve analysis (DCA). Our study comprised a total of 1259 individuals, who were further divided into training (n = 894) and validation (n = 365) cohorts. By identifying several common clinical features, we developed a nomogram that exhibited a concordance index of 0.809 in the training dataset. Notably, our findings demonstrated positive improvements in predictive performance through the IDI and NRI analyses in both cohorts. Furthermore, calibration curves indicated favorable agreement between the predicted and actual incidence of mortality (P > 0.05). DCA curves highlighted the substantial net clinical benefit of our nomogram compared to existing scoring systems used in routine clinical practice. In conclusion, our study successfully constructed and validated a prognostic nomogram, which enables accurate short-term mortality prediction in elderly individuals with ischemic stroke.

HS-CRP Modifies the Prognostic Value of Platelet Count for Clinical Outcomes After Ischemic Stroke

Background We examined whether the relationship between baseline platelet count and clinical outcomes is modulated by HS-CRP (high-sensitivity C-reactive protein) in patients with ischemic stroke. Methods and Results A total of 3267 patients with ischemic stroke were included in the analysis. The primary outcome was a combination of death and major disability at 1 year after ischemic stroke. Secondary outcomes included major disability, death, vascular events, composite outcome of vascular events or death, and an ordered 7-level categorical score of the modified Rankin Scale at 1 year. Multivariate logistic regression and Cox proportional hazards regression models were used to assess the association between the baseline platelet count and clinical outcomes stratified by HS-CRP levels when appropriate. There was an interaction effect of platelet count and HS-CRP on the adverse clinical outcomes after ischemic stroke (all P_interaction<0.05). The elevated platelet count was significantly associated with the primary outcome (odds ratio [OR], 3.14 [95% CI, 1.77-5.58]), major disability (OR, 2.07 [95% CI, 1.15-3.71]), death (hazard ratio [HR], 2.75 [95% CI, 1.31-5.79]), and composite outcome of vascular events or death (HR, 2.57 [95% CI, 1.38-4.87]) among patients with high HS-CRP levels (all P_trend<0.05). Conclusions The HS-CRP levels had a modifying effect on the association between platelet count and clinical outcomes in patients with ischemic stroke. Elevated platelet count was significantly associated with adverse clinical outcomes in patients with ischemic stroke with high HS-CRP levels, but not in those with low HS-CRP levels. These findings suggest that strategies for anti-inflammatory and antiplatelet therapy should be developed according to the results of both platelet and HS-CRP testing.

A Nomogram for Predicting the Recurrence of Acute Non-Cardioembolic Ischemic Stroke: A Retrospective Hospital-Based Cohort Analysis

Non-cardioembolic ischemic stroke (IS) is the predominant subtype of IS. This study aimed to construct a nomogram for recurrence risks in patients with non-cardioembolic IS in order to maximize clinical benefits. From April 2015 to December 2019, data from consecutive patients who were diagnosed with non-cardioembolic IS were collected from Lanzhou University Second Hospital. The least absolute shrinkage and selection operator (LASSO) regression analysis was used to optimize variable selection. Multivariable Cox regression analyses were used to identify the independent risk factors. A nomogram model was constructed using the "rms" package in R software via multifactor Cox regression. The accuracy of the model was evaluated using the receiver operating characteristic (ROC), calibration curve, and decision curve analyses (DCA). A total of 729 non-cardioembolic IS patients were enrolled, including 498 (68.3%) male patients and 231 (31.7%) female patients. Among them, there were 137 patients (18.8%) with recurrence. The patients were randomly divided into training and testing sets. The Kaplan-Meier survival analysis of the training and testing sets consistently revealed that the recurrence rates in the high-risk group were significantly higher than those in the low-risk group (p < 0.01). Moreover, the receiver operating characteristic curve analysis of the risk score demonstrated that the area under the curve was 0.778 and 0.760 in the training and testing sets, respectively. The nomogram comprised independent risk factors, including age, diabetes, platelet-lymphocyte ratio, leukoencephalopathy, neutrophil, monocytes, total protein, platelet, albumin, indirect bilirubin, and high-density lipoprotein. The C-index of the nomogram was 0.752 (95% CI: 0.705~0.799) in the training set and 0.749 (95% CI: 0.663~0.835) in the testing set. The nomogram model can be used as an effective tool for carrying out individualized recurrence predictions for non-cardioembolic IS.

Platelet count in preeclampsia: a systematic review and meta-analysis

OBJECTIVE

Many studies have reported the association between platelets and preeclampsia. However, sample sizes were small, and their findings were inconsistent. We conducted a systematic review and meta-analysis to evaluate the association in pooled samples and in detail.

DATA SOURCES

A systematic literature search was performed using Medline, Embase, ScienceDirect, Web of Science, Cochrane Library, NICHD-DASH, LILACS, and Scopus from inception to April 22, 2022.

STUDY ELIGIBILITY CRITERIA

Observational studies comparing platelet count between women with preeclampsia and normotensive pregnant women were included.

METHODS

The mean differences with 95% confidence interval in platelet count were calculated. Heterogeneity was assessed using I2 statistics. Sensitivity and subgroup analyses were conducted. Statistical analysis was performed using RevMan 5.3 and ProMeta 3 software.

RESULTS

A total of 56 studies comprising 4892 preeclamptic and 9947 normotensive pregnant women were included. Meta-analysis showed that platelet count was significantly lower in women with preeclampsia than in normotensive controls (overall: mean difference, -32.83; 95% confidence interval, -40.13 to -25.52; P<.00001; I2=92%; mild preeclampsia: mean difference, -18.65; 95% confidence interval, -27.17 to -10.14; P<.00001; I2=84%; severe preeclampsia: mean difference, -42.61; 95% confidence interval, -57.53 to -27.68; P<.00001; I2=94%). Significantly lower platelet count was also observed in the second trimester (mean difference, -28.84; 95% confidence interval, -44.59 to -13.08; P=.0003; I2=93%), third trimester (mean difference, -40.67; 95% confidence interval, -52.14 to -29.20; P<.00001; I2=92%), and before the diagnosis of preeclampsia (mean difference, -18.81; 95% confidence interval, -29.98 to -7.64; P=.009; I2=87%), but not in the first trimester (mean difference, -15.14; 95% confidence interval, -37.71 to 7.43; P=.19; I2=71%). Overall, the pooled sensitivity and specificity of platelet count were 0.71 and 0.77, respectively. The area under the curve was 0.80.

CONCLUSION

This meta-analysis confirmed that platelet count was significantly lower in preeclamptic women, irrespective of severity and presence or absence of associated complications, even before the onset of preeclampsia and in the second trimester of pregnancy. Our findings suggest that platelet count may be a potential marker to identify and predict preeclampsia.

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

BACKGROUND AND AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Association between red cell distribution width-to-platelet ratio and short-term and long-term mortality risk in patients with acute ischemic stroke

BACKGROUND

The objective of this study was to evaluate the association between red cell distribution width/platelet ratio (RPR) and 30-day and 1-year mortality in acute ischemic stroke (AIS).

METHODS

Data for the retrospective cohort study were collected from the Medical Information Mart for Intensive Care (MIMIC) III database. RPR was divided into two groups: RPR ≤ 0.11 and RPR > 0.11. The study outcomes were 30-day mortality and 1-year mortality from AIS. Cox proportional hazard models were utilized to assess the association between RPR and mortality. Subgroup analyses were applied based on age, tissue-type plasminogen activator (IV-tPA), endovascular treatment, and myocardial infarction.

RESULTS

A total of 1,358 patients were included in the study. Short- and long-term mortality occurred in 375 (27.61%) and 560 (41.24%) AIS patients, respectively. A high RPR was significantly associated with increased 30-day [hazard ratio (HR): 1.45, 95% confidence interval (CI): 1.10 to 1.92, P = 0.009] and 1-year mortality (HR: 1.54, 95%CI: 1.23 to 1.93, P < 0.001) in AIS patients. Meanwhile, RPR was found to be significantly related to 30-day mortality in AIS patients aged < 65 years (HR: 2.19, 95% CI: 1.17 to 4.10, P = 0.014), without IV-tPA use (HR: 1.42, 95% CI: 1.05 to 1.90, P = 0.021), without using endovascular treatment (HR: 1.45, 95% CI: 1.08 to 1.94, P = 0.012), and without myocardial infarction (HR: 1.54, 95% CI: 1.13 to 2.10, P = 0.006). Additionally, RPR was associated with 1-year mortality in AIS patients aged < 65 years (HR: 2.54, 95% CI: 1.56 to 4.14, P < 0.001), aged ≥ 65 years (HR: 1.38, 95% CI: 1.06 to 1.19, P = 0.015), with (HR: 1.46, 95% CI: 1.15 to 1.85, P = 0.002) and without using IV-tPA (HR: 2.30, 95% CI: 1.03 to 5.11, P = 0.041), without using endovascular treatment (HR: 1.56, 95% CI: 1.23 to 1.96, P < 0.001), and without myocardial infarction (HR: 1.68, 95% CI: 1.31 to 2.15, P < 0.001).

CONCLUSION

Elevated RPR is associated with a high risk of short-term and long-term mortality in AIS.

Red blood cell distribution width to platelet ratio predicts early neurological deterioration in acute ischemic stroke patients receiving intravenous thrombolysis

BACKGROUND

Inflammation plays a prominent role in the pathogenesis and progression of acute ischemic stroke (AIS). The red blood cell distribution width to platelet ratio (RPR) has been demonstrated as a novel biomarker to indicate the severity of inflammatory reaction. This study aimed to explore the association between RPR before intravenous thrombolysis and early neurological deterioration (END) after thrombolysis in AIS patients.

METHODS

AIS patients accepting intravenous thrombolysis were recruited continuously. Postthrombolysis END was defined as death or an increase in the National Institute of Health Stroke Scale (NIHSS) score ≥4 points within 24 h after intravenous thrombolysis compared to the NIHSS score before intravenous thrombolysis. We constructed univariate and multivariate logistic regression analyses to investigate the relationship of RPR before intravenous thrombolysis to postthrombolysis END. Moreover, a receiver operating characteristic (ROC) curve was applied to examine the discriminative utility of RPR before intravenous thrombolysis in predicting postthrombolysis END.

RESULTS

A total of 235 AIS patients were included, and 31 (13.19%) subjects underwent postthrombolysis END. The univariate logistic regression analysis demonstrated that RPR before intravenous thrombolysis was significantly related to postthrombolysis END (odds ratio [OR], 2.162; 95% confidence interval [CI], 1.605-2.912; P < 0.001). After adjusting for potential confounding variables with P < 0.15 in the univariate logistic regression analysis, the difference remained statistically significant (OR, 2.031; 95% CI, 1.436-2.873; P < 0.001). Furthermore, an optimal cutoff value of 7.66 for RPR before intravenous thrombolysis in predicting postthrombolysis END was observed in the ROC curve analysis, and the sensitivity and specificity were calculated as 61.3% and 81.9%, respectively (area under the curve [AUC], 0.772; 95% CI, 0.684-0.860; P < 0.001).

CONCLUSIONS

RPR before intravenous thrombolysis might be an independent risk factor for postthrombolysis END in AIS patients. Elevated levels of RPR before intravenous thrombolysis may predict postthrombolysis END.

Impact of thrombocytopenia on hemorrhagic complications after endovascular therapy for acute large vessel occlusion: Sub-analysis of RESCUE-Japan registry 2

BACKGROUND

Endovascular treatment (EVT) for patients with large vessel occlusion (LVO) and concurrent thrombocytopenia raises concerns about hemorrhagic complications. We examined the association between thrombocytopenia and clinical outcomes after EVT.

METHODS

This is a sub-analysis of the RESCUE-Japan Registry 2, a nationwide registry that enrolled 2420 consecutive acute LVO patients. We evaluated the clinical outcomes in patients who underwent EVT according to their platelet count on admission (Moderate/Severe, < 100 × 10⁹ /L; Mild, 100 to ≤150 × 10⁹/L; Normal, ≥ 150 × 10⁹/L). The outcomes included any and symptomatic intracranial hemorrhage (ICH) after EVT, and modified Rankin Scale (mRS) at 90 days.

RESULTS

Of 1268 patients who underwent EVT, the Moderate/Severe and Mild groups consisted of 41 (3.2%), and 193 (15.2%) patients. Any ICH occurred in 37%, 35%, and 24% of Moderate/Severe, Mild, and Normal group patients, respectively, and the adjusted ORs (95% CIs) were 1.50 (0.71-3.18) for Moderate/Severe and 1.87 (1.28-2.73) for Mild, compared to the Normal group (p for trend = 0.004). Symptomatic ICH increased with the severity of thrombocytopenia (9.8% vs 3.6% vs 2.1%), and adjusted ORs were 4.43 (1.16-17.0) in Moderate/Severe and 1.85 (0.71-4.86) in Mild (p for trend = 0.10). Mortality was significantly associated with the severity of thrombocytopenia (p for trend = 0.005), and adjusted ORs were 3.26 (1.29-8.26) in the Moderate/Severe and 2.76 (1.58-4.84) in the Mild groups.

CONCLUSIONS

Thrombocytopenia in LVO patients was not rare and associated with the incidence and manifestation of ICH after EVT.

Probability of Cardioembolic vs. Atherothrombotic Pathogenesis of Cryptogenic Strokes in Older Patients

Some clinical, laboratory, ECG, and echocardiographic parameters could provide useful indications to assess the probability of cardioembolism or atherothrombosis in cryptogenic strokes. We retrospectively examined 290 patients with ischemic stroke aged ≥60 years, divided into 3 groups: strokes originating from large artery atherothrombosis (n = 92), cardioembolic strokes caused by paroxysmal atrial fibrillation (n = 88) and cryptogenic strokes (n = 110). In addition to echocardiographic and routine clinical-laboratory variables, neutrophil:lymphocyte ratio, red blood cell distribution width, mean platelet volume, P wave and PR interval duration and biphasic inferior P waves, both on admission and after 7 to 10 days, were also considered. By multiple logistic regression, cardioembolic strokes were compared with large artery atherothrombosis strokes, and beta coefficients were rounded to produce a scoring system. Late PR interval ≥188 ms, left atrium ≥4 cm, left ventricular end-diastolic volume <65 ml, and posterior circulation syndrome were associated with paroxysmal atrial fibrillation (positive scores). In contrast, male gender, hypercholesterolemia, and initial platelet count ≥290 × 10⁹/L were associated with atherothrombosis of large arteries (negative scores). The algebraic sum of these scores produced values indicative of cardioembolism if >0 (positive predictive value 89.1%), or of atherothrombosis, if ≤0 (positive predictive value 72.5%). The area under the receiver operating characteristic curve was 0.85. Among cryptogenic strokes, 41.5% had a score >0 (probable atrial fibrillation) and 58.5% had a score ≤0 (possible atherothrombosis). In conclusion, a scoring system based on electrocardiogram, laboratory, clinical and echocardiographic parameters can provide useful guidance for further investigations and secondary prevention in older patients with cryptogenic stroke.

Assessment of Atherosclerosis in Ischemic Stroke by means of Ultrasound of Extracranial/Intracranial Circulation and Serum, Urine, and Tissue Biomarkers

It is a common practice to take into consideration age, diabetes, smoking, treated and untreated systolic blood pressure, total cholesterol, and high-density lipoprotein cholesterol for the prediction of atherosclerosis and stroke. There are, however, ultrasound markers in use for the assessment of atherosclerosis and the evaluation of stroke risk. Two areas of investigation are of interest: the carotid artery and the intracranial arterial circulation. Again, within the domain of the carotid artery, two ultrasonic markers have attracted our attention: intima media thickness of the carotid artery and the presence of carotid plaque with its various focal characteristics. In the domain of intracranial circulation, the presence of arterial stenosis and the recruitment of collaterals are considered significant ultrasonic markers for the above-mentioned purpose. On the other hand, a series of serum, urine, and tissue biomarkers are found to be related to atherosclerotic disease. Future studies might address the issue of whether the addition of proven ultrasonic carotid indices to the aforementioned serum, urine, and tissue biomarkers could provide the vascular specialist with a better assessment of the atherosclerotic load and solidify their position as surrogate markers for the evaluation of atherosclerosis and stroke risk.

The HALP (hemoglobin, albumin, lymphocyte, and platelet) score is associated with early-onset post-stroke cognitive impairment

BACKGROUND

The HALP score (hemoglobin, albumin, lymphocyte, and platelet) is a novel indicator that measures systemic inflammation and nutritional status. The goal of this study was to look into the relationship between the HALP score and post-stroke cognitive impairment (PSCI) in people who had an acute ischemic stroke (AIS).

METHODS

A total of 592 individuals with ischemic stroke were included in the research, and the PSCI (n = 382) and non-PSCI (n = 210) groups were determined using the Mini-Mental State Examination scale 2 weeks following the stroke. HALP score was computed by the formula: hemoglobin (g/L) × albumin (g/L) × lymphocytes (/L) / platelets (/L), and was split into three layers according to the tertiles. The connection between the HALP and cognitive results was investigated by binary logistic regression.

RESULTS

The PSCI group's HALP score was much lower than the non-PSCI group's (p < 0.001). The HALP score was divided into three layers: T1 ≤ 34.0, T2 34.1-49.4, and T3 ≥ 49.5, respectively. In the binary regression analysis, taking the T3 layer as the reference, the T1 layer showed the highest risk of PSCI after adjusting for confounding factors (odds ratio (OR) = 1.965, 95% confidence interval (CI) = 1.237-3.122, p = 0.004), while there was no increased risk of PSCI in the T2 layer (OR = 1.538, 95%CI = 0.983-2.404, p = 0.059).

CONCLUSION

Low HALP score at admission was found to be correlated with early-onset PSCI and may help clinicians in the early identification of high-risk patients.

Prognostic Role of the Platelet-Lymphocyte Ratio in Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy: A Meta-Analysis

Background

Both inflammation and thrombotic/hemostatic mechanisms may play a role in acute ischemic stroke (AIS) pathogenesis, and a biomarker, such as the platelet-to-lymphocyte ratio (PLR), considering both mechanisms may be of clinical utility.

Objectives

This meta-analysis sought to examine the effect of PLR on functional outcomes, early neurological changes, bleeding complications, mortality, and adverse outcomes in AIS patients treated with reperfusion therapy (RT).

Design

Systematic Review and Meta-Analysis

Data Sources and Methods

Individual studies were retrieved from the PubMed/Medline, EMBASE and Cochrane databases. References thereof were also consulted. Data were extracted using a standardised data sheet, and systematic reviews and meta-analyses on the association of admission (pre-RT) or delayed (post-RT) PLR with defined clinical and safety outcomes were conducted. In the case of multiple delayed PLR timepoints, the timepoint closest to 24 hours was selected.

Results

Eighteen studies (n=4878) were identified for the systematic review, of which 14 (n=4413) were included in the meta-analyses. PLR collected at admission was significantly negatively associated with 90-day good functional outcomes (SMD=−.32; 95% CI = −.58 to −.05; P=.020; z=−2.328), as was PLR collected at delayed timepoints (SMD=−.43; 95% CI = −.54 to −.32; P<.0001; z=−7.454). PLR at delayed timepoints was also significantly negatively associated with ENI (SMD=−.18; 95% CI = −.29 to −.08; P=.001. Conversely, the study suggested that a higher PLR at delayed timepoints may be associated with radiological bleeding and mortality. The results varied based on the type of RT administered.

Conclusions

A higher PLR is associated with worse outcomes after stroke in terms of morbidity, mortality, and safety outcomes after stroke.

Prevalence and Risk Factors of Cardiovascular Disease in Patients with Chronic Hepatitis B

BACKGROUND

The association between chronic hepatitis B (CHB) and cardiovascular disease (CVD) remains unclear. We investigated the prevalence and risk factors of CVD in patients with CHB.

METHODS

Data from the Korean National Health and Nutrition Examination Surveys 2008-2011 were analyzed. Significant liver fibrosis was defined as the highest nonalcoholic fatty liver disease fibrosis score quartile, highest Forns index quintile, or fibrosis-4 ≥ 2.67. The CVD risk was calculated using the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score from the 2013 ACC/AHA Guidelines.

RESULTS

Among the 506 subjects with CHB, 15 (3.0%) and 150 (29.6%) patients had a CVD history and significant liver fibrosis, respectively. Patients with CVD history were significantly older; showed a significantly higher prevalence of hypertension, metabolic syndrome, and significant liver fibrosis; and had a significantly higher platelet count, lower aspartate and alanine aminotransferase levels, higher triglyceride level, lower high-density lipoprotein level, and higher ASCVD risk than those without (all p < 0.05). In multivariate analysis, higher ASCVD risk (odds ratio [OR] = 1.090) and significant liver fibrosis (OR = 4.341) independently predicted the risk of CVD history (p < 0.05). The prevalence of CVD risk (6.7% vs. 1.4%; OR = 5.014) and high ASCVD risk (> 15%) (34.0% vs. 7.3%; OR = 6.538) was significantly higher in patients with significant liver fibrosis than in those without (all p < 0.05).

CONCLUSIONS

Significant liver fibrosis was independently associated with the risk of CVD history in patients with CHB. Prospective studies are needed to validate the longitudinal association between fibrotic burden and CVD development in patients with CHB.

Prevalence and Risk Factors of Cardiovascular Disease in Patients with Chronic Hepatitis B

BACKGROUND

The association between chronic hepatitis B (CHB) and cardiovascular disease (CVD) remains unclear. We investigated the prevalence and risk factors of CVD in patients with CHB.

METHODS

Data from the Korean National Health and Nutrition Examination Surveys 2008-2011 were analyzed. Significant liver fibrosis was defined as the highest nonalcoholic fatty liver disease fibrosis score quartile, highest Forns index quintile, or fibrosis-4 ≥ 2.67. The CVD risk was calculated using the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score from the 2013 ACC/AHA Guidelines.

RESULTS

Among the 506 subjects with CHB, 15 (3.0%) and 150 (29.6%) patients had a CVD history and significant liver fibrosis, respectively. Patients with CVD history were significantly older; showed a significantly higher prevalence of hypertension, metabolic syndrome, and significant liver fibrosis; and had a significantly higher platelet count, lower aspartate and alanine aminotransferase levels, higher triglyceride level, lower high-density lipoprotein level, and higher ASCVD risk than those without (all p < 0.05). In multivariate analysis, higher ASCVD risk (odds ratio [OR] = 1.090) and significant liver fibrosis (OR = 4.341) independently predicted the risk of CVD history (p < 0.05). The prevalence of CVD risk (6.7% vs. 1.4%; OR = 5.014) and high ASCVD risk (> 15%) (34.0% vs. 7.3%; OR = 6.538) was significantly higher in patients with significant liver fibrosis than in those without (all p < 0.05).

CONCLUSIONS

Significant liver fibrosis was independently associated with the risk of CVD history in patients with CHB. Prospective studies are needed to validate the longitudinal association between fibrotic burden and CVD development in patients with CHB.

Association of Platelet-to-Lymphocyte Ratio with Stroke-Associated Pneumonia in Acute Ischemic Stroke

A common consequence of acute ischemic stroke (AIS), stroke-associated pneumonia (SAP), might result in a poor prognosis after stroke. Based on the critical position of inflammation in SAP, this study aimed to explore the correlation between platelet-to-lymphocyte ratio (PLR) and the occurrence of SAP. We included 295 patients with acute ischemic stroke, 40 with SAP, and 255 without SAP. The area under the receiver operating characteristic curve was used to determine the diagnostic value of SAP risk factors using binary logistic regression analysis. The comparison between the two groups showed that age, the baseline National Institutes of Health Stroke Scale (NIHSS) score, and the proportion of dysphagia, atrial fibrillation, and total anterior circulation infarct were higher, and the proportion of lacunar circulation infarct was lower in the SAP group (P < 0.001). In terms of laboratory data, the SAP group had considerably greater neutrophil counts and PLR, while the non-SAP group (P < 0.001) had significantly lower lymphocyte counts and triglycerides. Binary logistic regression analysis revealed that older age (aOR = 1.062, 95% CI: 1.023–1.102, P = 0.002), atrial fibrillation (aOR = 3.585, 95% CI: 1.605–8.007, P = 0.019), and PLR (aOR = 1.003, 95% CI: 1.001–1.006, P = 0.020) were independent risk factors associated with SAP after adjusting for potential confounders. The sensitivity and specificity of PLR with a cutoff value of 152.22 (AUC: 0.663, 95% CI: 0.606–0.717, P = 0.0006) were 57.5% and 70.6%, respectively. This study showed that high PLR is an associated factor for SAP in AIS patients. Increased systemic inflammation is linked to SAP in ischemic stroke. Inflammatory biomarkers that are easily accessible may aid in the diagnosis of high-risk SAP patients.

Protection against Neurological Symptoms by Consuming Corn Silk Water Extract in Artery-Occluded Gerbils with Reducing Oxidative Stress, Inflammation, and Post-Stroke Hyperglycemia through the Gut-Brain Axis

Corn silk (Stigma maydis), rich in flavonoids, is traditionally used to treat edema, depression, and hyperglycemia and may alleviate ischemic stroke symptoms in Chinese medicine. This study examined whether corn silk water extract (CSW) could alleviate ischemic stroke symptoms and post-stroke hyperglycemia in Mongolian gerbils with transient cerebral ischemia and reperfusion (I/R). After being given 0.05% (I/R-LCSW) and 0.2% (I/R-HCSW), 0.02% aspirin (I/R-aspirin), and cellulose (I/R-control) in their 40 energy% fat diets for three weeks, the gerbils underwent an artery occlusion for eight minutes and reperfusion. They took the assigned diet for an additional three weeks. Sham-operated gerbils without artery occlusion had the same diet as Sham-control. CSW intake reduced neuronal cell death in gerbils with I/R and dose-dependently improved the neurological symptoms, including drooped eyes, crouched posture, flexor reflex, and walking patterns. CSW intake also alleviated the short-term memory and spontaneous alteration and grip strength compared to the I/R-control group. The protection against ischemic stroke symptoms was associated with the reduced tumor necrosis factor-α, interleukin-1β, superoxide, and lipid peroxide levels, promoting superoxide dismutase activity in the hippocampus in the CSW groups, compared to the I/R-control. The blood flow measured by Doppler was improved with CSW compared to the I/R-control. Furthermore, CSW intake prevented the post-stroke hyperglycemia related to decreasing pancreatic β-cell mass as much as the Sham-control, and it was related to protection against β-cell apoptosis, restoring the β-cell mass similar to the Sham-control. CSW intake elevated the relative abundance of Lactobacillus, Bifidobacterium, Allobaculum, and Akkermansia compared to the I/R-control. Picrust2 analysis showed that CSW increased the propionate and butyrate metabolism and the starch and glucose metabolism but reduced lipopolysaccharide biosynthesis compared to the I/R-control. In conclusion, CSW intake protects against neuronal cell death and post-hyperglycemia by reducing oxidative stress and inflammation and increasing blood flow and the β-cell mass. The alleviation was associated with promoting the gut-brain axis by changing the gut microbiome community.

Diagnostic and Prognostic Blood Biomarkers in Transient Ischemic Attack and Minor Ischemic Stroke: An Up-To-Date Narrative Review

INTRODUCTION

Early diagnosis and correct risk stratification in patients with transient ischemic attack (TIA) and minor ischemic stroke (MIS) is crucial for the high rate of subsequent disabling stroke. Although highly improved, diagnosis and prognostication of TIA/MIS patients remain still based on clinical and neuroimaging findings, with some inter-rater variability even among trained neurologists.

OBJECTIVES

To provide an up-to-date overview of diagnostic and prognostic blood biomarkers in TIA and MIS patients.

MATERIAL AND METHODS

We performed a bibliographic search on PubMed database with last access on July 10^th 2021. More than 680 articles were screened and we finally included only primary studies on blood biomarkers.

RESULTS

In a narrative fashion, we discussed about blood biomarkers investigated in TIA/MIS patients, including inflammatory, thrombosis, neuronal injury and cardiac analytes, antibodies and microRNAs. Other soluble molecules have been demonstrated to predict the risk of recurrent cerebrovascular events or treatment response in these patients. A rapid point of care assay, combining the determination of different biomarkers, has been developed to improve triage recognition of acute cerebrovascular accidents.

CONCLUSIONS

The implementation of blood biomarkers in the clinical management of TIA/MIS could ameliorate urgent identification, risk stratification and individual treatment choice. Large prospective and longitudinal studies, adopting standardized sampling and analytic procedures, are needed to clarify blood biomarkers kinetic and their relationship with TIA and minor stroke etiology.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Increased Platelet-to-Lymphocyte Ratio is an Independent Predictor of Hemorrhagic Transformation and In-Hospital Mortality Among Acute Ischemic Stroke with Large-Artery Atherosclerosis Patients

Background

The platelet-to-lymphocyte ratio (PLR) is an inflammation marker of acute ischemic stroke, but its significance in patients with hemorrhage transformation (HT) after acute ischemic stroke with large-artery atherosclerosis (AIS-LAA) is unclear, and we also identified the relationship between PLR and in-hospital mortality of HT after AIS-LAA.

Methods

This was a retrospective analysis of patients with AIS-LAA. The PLR was calculated according to platelet and lymphocyte counts on admission. HT was defined on follow-up magnetic resonance imaging or computed tomography when neurologic deterioration worsened during hospitalization. The univariate analysis and multivariate logistic regression were performed to assess the association of PLR, HT and in-hospital mortality of HT after AIS-LAA.

Results

We included 328 Chinese AIS-LAA patients (mean age 67.2±11.1 years; 70.4% male). HT occurred in 38 patients (11.6%). After multivariate regression analyses, NRL (odds ratio [OR] 1.354, 95% confidence interval [CI] 1.176–1.559, P<0.001) and PLR (odds ratio [OR] 3.869, 95% confidence interval [CI] 2.233–5.702, P<0.001) were independently associated with HT after AIS-LAA. The area under the ROC curve (AUC) value of PLR (0.72, 95% CI (0.64–0.80), P<0.001) tested a greater discriminatory ability compared with neutrophil-lymphocyte ratio (NLR) (0.67, 95% CI (0.58–0.76), P<0.001). Meanwhile, PLR was found to be significantly related to HT after AIS-LAA, including in subtypes of artery-to-artery embolization (aOR 1.699, 95% CI 1.298–3.215, P<0.001), in-situ thrombosis (aOR4.499, 95% CI 1.344–9.054, P<0.001) and branch atheromatous disease (aOR3.239, 95% CI 1.098–8.354, P<0.001). Increased PLR predicts high in-hospital mortality of HT after AIS-LAA (OR 1.041, 95% CI (1.006–1.077), P=0.020; aOR 1.053, 95% CI (1.004–1.104), P=0.034).

Conclusion

High PLR is associated with greater risk of HT in AIS-LAA patients, including in artery-to-artery embolization, in-situ thrombosis and branch atheromatous disease. Meanwhile, increased PLR predicts high in-hospital mortality of HT after AIS-LAA.

Evaluation of combining Alberta Stroke Program Early CT Score (ASPECTS) with mean platelet volume, plateletcrit, and platelet count in predicting short- and long-term prognosis of patients with acute ischemic stroke

BACKGROUND

There is controversy regarding Alberta Stroke Program Early CT Score (ASPECTS) and platelet indices as predictors of outcome in patients with acute ischemic stroke (AIS). We aimed to assess the prognostic value of ASPECTS, mean platelet volume (MPV), plateletcrit (PCT), and platelet count (Plt) in 3-month and 1-year functional outcomes of AIS patients, both independently and in combination.

METHODS

This prospective study was conducted in Shams Al-shomuos and Ghaem hospitals of Mashhad, Iran from June 2019 to January 2021. Overall, 553 patients above 18 years old with first-ever anterior circulation AIS met the eligibility criteria and were included. Clinical, hematologic, radiologic, and demographic data of patients were recorded at baseline. The 3-month and 1-year functional outcome was evaluated by modified Rankin Scale (mRS). Multivariate logistic regression was used to determine the independent predictors of poor functional outcome (mRS>2) and mortality.

RESULTS

The mean age of the patients was 65.50 ± 14.41 years and 282 patients (51%) were male. ASPECTS ≤ 7 was an independent predictor of both poor function (OR=1.94, 95%CI=1.04-3.62, P = 0.04) and mortality (OR=2.02, 95%CI=1.14-3.58, P = 0.02) at 1 year. MPV was also a strong predictor of 3-month (OR=3.88, 95%CI=2.04-7.38, P = 0.02) and 1-year (OR=3.32, 95%CI=1.91-5.78, P = 0.01) mortality, as well as 3-month (OR=3.25, 95%CI=1.80-5.86, P < 0.001) and 1-year (OR=4.35, 95%CI=2.36-8.02, P < 0.001) poor function. For 1-year poor function (OR=9.33, 95%CI=2.19-39.73, P = 0.003) and mortality (OR=6.40, 95%CI=2.09-19.64, P = 0.001), ASPECTS combined with all platelet indices found to be a more robust independent predictor compared to each variable alone.

CONCLUSION

Although MPV is an independent predictor of both 3-month and 1-year poor function and mortality in AIS patients, ASPECTS ≤ 7 was found to be a risk factor for 1-year poor function and mortality. Moreover, the prognostic value of both platelet indices and ASPECTS are greater when they are combined together in AIS patients.

The Survival Status and Predictors of Mortality Among Stroke Patients at North West Ethiopia

INTRODUCTION

Stroke is one of the commonest non-communicable disease types that has a great public health impact both in developed and developing countries. However, in Ethiopia, the long-term survival status of stroke patients is not very understood. This study aimed at assessing survival status and predictors of mortality among stroke patients at Felege Hiwot comprehensive specialized hospital from September 1, 2014, to August 31, 2019, Bahirdar, North West Ethiopia.

METHODS

An institutional-based retrospective cohort study was conducted using 368 registered stroke patients between September 1, 2014, and August 31, 2019. We used Kaplan-Meier together with a Log-rank test to compare the survival rate of the study participants using categorical variables and to compare covariate and both bi-variable and multivariable Cox proportional hazards regression analysis model was conducted to identify predictors of mortality among stroke patients. The association between outcome and independent variables was expressed using an adjusted hazard ratio (AHR) with a 95% confidence interval and statistical significances were declared at P-value of <0.05.

RESULTS

Fifty-six (15.2%) of the 368 stroke patients included in the study died, and 312 (84.8%) were correctly censored. The overall survival rate was 72.2% at 51 months of follow-up with a median survival time of 0.26 months. Age greater than 65 (AHR 6.31, 95% CI 1.75-22.74), body temperature >7.1 degree centigrade (AHR = 7.14, 95% CI: 2.76-18.5), potassium level below <2 mmol/l (AHR = 2, 95% CI: 1.9-23.53) and creatinine level >1.2 mg/dl (AHR = 7.85, 95% CI: 2.7-22.6) were predictive predictors of mortality.

CONCLUSIONS

In the follow-up of 51 months, significant mortality occurred. Important predictive predictors of survival status were identified. Interventions should be focused on health education and awareness creation of the community for the early management of stroke.

"Case series: ischemic stroke associated with dehydration and arteriosclerosis in individuals with severe anorexia nervosa"

BACKGROUND

Numerous reports have indicated that patients with anorexia nervosa (AN) are at a relatively high risk of developing vascular diseases, including cardiovascular events and venous thromboembolism. However, there have been no previous reports of the development of ischemic stroke during refeeding therapy in patients with severe AN. This report is aimed at reporting the characteristics of an ischemic stroke in patients with AN.

CASE PRESENTATIONS

Our study included 29 admissions by independent 19 female patients cases (19 patients), who received thorough medical, neurological, and psychiatric examinations. Two patients were diagnosed as having developed ischemic stroke; the first patient showed multiple infarctions in the brain, while the second showed symptomatic focal infarction. Our findings suggest that dehydration and arteriosclerosis, in association with severe malnutrition, could predispose to the development of ischemic stroke in patients with severe AN.

CONCLUSIONS

Development of ischemic stroke in patients with AN might be overlooked. Watching out for neurological signs would help in early diagnosis of ischemic stroke in patients with AN during refeeding. Specific etiology could induce ischemic stroke in patients with AN even if they have no common risk factors of ischemia.

The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) Score Is Associated With Poor Outcome of Acute Ischemic Stroke

Background: The combined index of hemoglobin, albumin, lymphocyte, and platelet (HALP) is considered a novel score to reflect systemic inflammation and nutritional status. This study aimed to investigate the association between HALP score and poor outcome in patients with acute ischemic stroke (AIS). Methods: Consecutive AIS patients within 24 h after onset were prospectively enrolled. Poor outcome was a combination of a new stroke event (ischemic and hemorrhagic) and all-cause death within 90 days and 1 year. The association between HALP score and poor outcome was analyzed using Cox proportional hazards. Results: A total of 1,337 patients were included. Overall, 60 (4.5%) and 118 (8.8%) patients experienced poor outcome within 90 days and 1 year, respectively. Patients in the highest tertile of HALP score had a lower risk of poor outcome within 90 days and 1 year (hazard ratio: 0.25 and 0.42; 95% confidence intervals: 0.11-0.57 and 0.25-0.69, P for trend <0.01 for all) compared with those in the lowest tertile after adjusting relevant confounding factors. Adding HALP score to the conventional risk factors improved prediction of poor outcome in patients with AIS within 90 days and 1 year (net reclassification index, 48.38 and 28.95%; integrated discrimination improvement, 1.51 and 1.51%; P < 0.05 for all). Conclusions: Increased HALP score was associated with a decreased risk of recurrent stroke and death within 90 days and 1 year after stroke onset, suggesting that HALP score may serve as a powerful indicator for AIS.

Machine Learning Analysis of the Cerebrovascular Thrombi Proteome in Human Ischemic Stroke: An Exploratory Study

Objective: Mechanical retrieval of thrombotic material from acute ischemic stroke patients provides a unique entry point for translational research investigations. Here, we resolved the proteomes of cardioembolic and atherothrombotic cerebrovascular human thrombi and applied an artificial intelligence routine to examine protein signatures between the two selected groups.

Methods: We specifically used n = 32 cardioembolic and n = 28 atherothrombotic diagnosed thrombi from patients suffering from acute stroke and treated by mechanical thrombectomy. Thrombi proteins were successfully separated by gel-electrophoresis. For each thrombi, peptide samples were analyzed by nano-flow liquid chromatography coupled to tandem mass spectrometry (nano-LC-MS/MS) to obtain specific proteomes. Relative protein quantification was performed using a label-free LFQ algorithm and all dataset were analyzed using a support-vector-machine (SVM) learning method. Data are available via ProteomeXchange with identifier PXD020398. Clinical data were also analyzed using SVM, alone or in combination with the proteomes.

Results: A total of 2,455 proteins were identified by nano-LC-MS/MS in the samples analyzed, with 438 proteins constantly detected in all samples. SVM analysis of LFQ proteomic data delivered combinations of three proteins achieving a maximum of 88.3% for correct classification of the cardioembolic and atherothrombotic samples in our cohort. The coagulation factor XIII appeared in all of the SVM protein trios, associating with cardioembolic thrombi. A combined SVM analysis of the LFQ proteome and clinical data did not deliver a better discriminatory score as compared to the proteome only.

Conclusion: Our results advance the portrayal of the human cerebrovascular thrombi proteome. The exploratory SVM analysis outlined sets of proteins for a proof-of-principle characterization of our cohort cardioembolic and atherothrombotic samples. The integrated analysis proposed herein could be further developed and retested on a larger patients population to better understand stroke origin and the associated cerebrovascular pathophysiology.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combined prognostic significance of D-dimer level and platelet count in acute ischemic stroke

BACKGROUND

D-dimer level and platelet count (PC) have been reported separately as significant independent predictors of Acute Ischemic Stroke (AIS). Here, we aimed to investigate the combined prognostic value of abnormal D-dimer level and PC as defined for specific in-hospital and long-term outcomes in AIS patients.

METHODS

A total of 1468 patients admitted for ischemic stroke within 24 h of symptom onset from April 1, 2016 to November 31, 2019 at the Department of Neurology, the First Affiliated Hospital of Harbin Medical University were included in the final analysis. Eligible subjects were divided into four groups in terms of their levels of D-dimer and PC: DD-PC- (normal D-dimer level and normal PC), DD-PC+ (normal D-dimer level and abnormal PC), DD+PC- (higher D-dimer level and normal PC), and DD+PC+ (higher D-dimer level and abnormal PC). Logistic regression model and multinomial logit model were used to estimate the combined effect of D-dimer level and PC on in-hospital outcomes including discharge outcome and early neurological changes, and poor outcomes at 3, 6 and 12 months.

RESULTS

DD+PC+ was found to be associated with the risk of in-hospital mortality (adjusted odds ratio [OR], 6.904; 95% confidence interval [CI], 2.781-17.144) and 3-month mortality (adjusted OR, 5.455; 95% CI, 2.019-14.743) compared with DD-PC-. Combination of the two indicators significantly improved the independent predictive value for functional outcomes, including early neurological deterioration (END) (OR, 3.622; 95% CI, 1.732-7.573) with threshold of at least 4-point increase on NIHSS, discharge outcome (OR, 2.713; 95% CI, 1.421-5.177); mRS of 0-1 point (OR, 0.409; 95% CI, 0.211-0.792), mRS of 0-2 points (OR, 0.234; 95% CI, 0.118, 0.461), and higher mRS-shift (OR, 2.379; 95% CI, 1.237-4.576) at 3 months; unfavorable outcome at 3 months (OR, 4.280; 95% CI, 2.169-8.446), 6 months (OR, 3.297; 95% CI, 1.452-7.488) and 12 months (OR, 4.157; 95% CI, 1.598-10.816). While comparatively weaker statistical significance was shown in DD+PC- and no correlation was found between adverse outcomes and DD-PC+. Similarly, patients with abnormal D-dimer level and PC were less likely to reach the status of stable or improving.

CONCLUSIONS

Combination of D-dimer level and PC may have more significant prognostic value on END, in-hospital mortality, discharge outcome, and long-term outcomes than either index of D-dimer level or PC alone in AIS patients.

Predictors of poor clinical outcome despite complete reperfusion in acute ischemic stroke patients

BACKGROUND

In patients suffering from acute ischemic stroke from large vessel occlusion (LVO), mechanical thrombectomy (MT) often leads to successful reperfusion. Only approximately half of these patients have a favorable clinical outcome. Our aim was to determine the prognostic factors associated with poor clinical outcome following complete reperfusion.

METHODS

Patients treated with MT for LVO from a prospective single-center stroke registry between July 2015 and April 2019 were screened. Complete reperfusion was defined as Thrombolysis in Cerebral Infarction (TICI) grade 3. A modified Rankin scale at 90 days (mRS90) of 3-6 was defined as 'poor outcome'. A logistic regression analysis was performed with poor outcome as a dependent variable, and baseline clinical data, comorbidities, stroke severity, collateral status, and treatment information as independent variables.

RESULTS

123 patients with complete reperfusion (TICI 3) were included in this study. Poor clinical outcome was observed in 67 (54.5%) of these patients. Multivariable logistic regression analysis identified greater age (adjusted OR 1.10, 95% CI 1.04 to 1.17; p=0.001), higher admission National Institutes of Health Stroke Scale (NIHSS) (OR 1.14, 95% CI 1.02 to 1.28; p=0.024), and lower Alberta Stroke Program Early CT Score (ASPECTS) (OR 0.6, 95% CI 0.4 to 0.84; p=0.007) as independent predictors of poor outcome. Poor outcome was independent of collateral score.

CONCLUSION

Poor clinical outcome is observed in a large proportion of acute ischemic stroke patients treated with MT, despite complete reperfusion. In this study, futile recanalization was shown to occur independently of collateral status, but was associated with increasing age and stroke severity.

The molecular basis of platelet biogenesis, activation, aggregation and implications in neurological disorders

Platelets are anucleated blood constituents, vital for hemostasis and involved in the pathophysiology of several cardiovascular, neurovascular diseases as well as inflammatory processes and metastasis. Over the past few years, the molecular processes that regulate the function of platelets in hemostasis and thrombosis have emerged revealing platelets to be perhaps more complex than may have been expected. The most understood part of platelets is to respond to a blood vessel injury by altering shape, secreting granule contents, and aggregating. These responses, while advantageous for hemostasis, can become detrimental when they root ischemia or infarction. Only a few transcription and signaling factors involved in platelet biogenesis have been identified till date. Platelets encompass an astonishingly complete array of organelles and storage granules including mitochondria, lysosomes, alpha granules, dense granules, a dense tubular system (analogous to the endoplasmic reticulum of nucleated cells); a highly invaginated plasma membrane system known as the open canalicular system (OCS) and large fields of glycogen. Platelets as a model cells to study neurological disorders have been recommended by several researchers since several counterparts exist between platelets and the brain, which make them interesting for studying the neurobiology of various neurological disorders. This review has been compiled with an aim to integrate the latest research on platelet biogenesis, activation and aggregation focusing on the molecular pathways that power and regulate these processes. The dysregulation of important molecular players affecting fluctuating platelet biology and thereby resulting in neurovascular diseases has also been discussed.

Higher Platelet-to-Lymphocyte Ratio Is Associated With Worse Outcomes After Intravenous Thrombolysis in Acute Ischaemic Stroke

Objective: The platelet-to-lymphocyte ratio (PLR) is a new marker of atherosclerotic inflammation and has been identified as a predictive factor in cardiovascular diseases, but its significance in patients with acute ischaemic stroke (AIS) who have undergone intravenous thrombolysis (IVT) is still unknown.

Methods: Consecutive patients who were treated with IVT using recombinant tissue plasminogen activator (rtPA) for AIS were included from May 2012 to August 2018. The PLR was calculated according to platelet and lymphocyte counts within 24 h after thrombolysis therapy. Functional outcomes were assessed by the modified Rankin Scale (mRS) at 3 months after thrombolysis. Stroke severity was assessed by National Institutes of Health Stroke Scale (NIHSS) scores. The primary endpoint was an unfavorable outcome (mRS > 2), and the secondary endpoint was death at 3 months.

Results: A total of 286 patients were included in the study. The median age was 69.5 (59.0–80.0) years, and 59.1% of patients were men. A total of 120 (42.0%) patients had an unfavorable outcome, and 38 (13.2%) died. Patients with an unfavorable outcome had significantly higher PLR values compared with those with a favorable outcome [172.5 (105.3–239.0) vs. 139 (97.0–194.5), P = 0.008], and the PLR values of the patients who died at 3 months were higher than those of the surviving patients [189.5 (127.5–289.0) vs. 142.0 (98.0–215.5), P = 0.006]. After adjustment for other variables, the PLR was independently associated with the two endpoints: unfavorable outcome (OR 2.220, 95% CI 1.245–3.957, P = 0.007) and death (OR 2.825, 95% CI 1.050–7.601, P = 0.040) at 3 months after thrombolysis. In addition, PLR was correlated with the NIHSS score (R = 0.230, P < 0.001).

Conclusions: Higher PLR levels were independently associated with an unfavorable outcome and death at 3 months in AIS patients treated with IVT.

DNA and RNA oxidative damage are associated to mortality in patients with cerebral infarction

OBJECTIVE

Secondary injury due to oxidation may occur during ischemic stroke, possibly leading to oxidative damage to deoxyribonucleic acid (DNA) and ribonucleic acid (RNA). Higher blood concentrations of 8-hydroxy-2'-deoxyguanosine (8-OHdG) (through the oxidation of guanosine from DNA) have been found in ischemic stroke patients than in healthy subjects, and in patients with versus without post-ischemic stroke depression. The present study was carried out to explore the possible association between serum DNA and RNA oxidative damage and mortality in patients with cerebral infarction.

METHODS

A prospective, multicenter observational study was carried out in the Intensive Care Units of 6 Spanish hospitals. We included patients with severe malignant middle cerebral artery infarction (MMCAI) defined as ischemic changes evidenced by computed tomography in more than 50% of the middle cerebral artery territory and a Glasgow Coma Score (GCS)<9. Serum concentrations of the three oxidized guanine species (OGS) (8-hydroxyguanine from DNA or RNA, 8-hydroxyguanosine from RNA, and 8-OHdG from DNA) on the day of MMCAI diagnosis were determined. The study endpoint was 30-day mortality.

RESULTS

We found higher serum OGS levels (p<0.001) in non-surviving (n=34) than in surviving patients (n=34). Logistic regression analyses showed serum OGS levels to be associated to 30-day mortality controlling for lactic acid, GCS and platelet count (OR=1.568; 95%CI=1.131-2.174; p=0.01).

CONCLUSIONS

The novel observation in this study is the association between global serum OGS concentration and mortality in ischemic stroke patients.