Endothelial and Leukocyte-Derived Microvesicles and Cardiovascular Risk After Stroke: PROSCIS-B

OBJECTIVE

To determine the role of circulating microvesicles (MV) on long-term cardiovascular outcomes after stroke, we measured them in patients with first-ever stroke with a 3-year follow-up.

METHODS

In the Prospective Cohort With Incident Stroke Berlin (PROSCIS-B), patients with first-ever ischemic stroke were followed up for 3 years. The primary combined endpoint consisted of recurrent stroke, myocardial infarction, and all-cause mortality. Citrate-blood levels of endothelial MV (EMV), leukocyte-derived MV (LMV), monocytic MV (MMV), and platelet-derived MV (PMV) were measured with flow cytometry. Kaplan-Meier curves and adjusted Cox proportional hazards models were used to estimate the effect of MV levels on the combined endpoint.

RESULTS

Five hundred seventy-one patients were recruited (median age 69 years, 39% female, median NIH Stroke Scale score 2, interquartile range 1-4), and 95 endpoints occurred. Patients with levels of EMV (adjusted hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.2-4.9) or LMV (HR 3.1, 95% CI 1.4-6.8) in the highest quartile were more likely to experience an event than participants with lower levels with the lowest quartile used as the reference category. The association was less pronounced for PMV (HR 1.7, 95% CI 0.9-3.2) and absent for MMV (HR 1.1, 95% CI 0.6-1.8).

CONCLUSION

High levels of EMV and LMV after stroke were associated with worse cardiovascular outcome within 3 years. These results reinforce that endothelial dysfunction and vascular inflammation affect the long-term prognosis after stroke. EMV and LMV might play a role in risk prediction for stroke patients.

CLINICALTRIALSGOV IDENTIFIER

NCT01363856.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence of the effect of MV levels on subsequent stroke, myocardial infarction, or all-cause mortality in survivors of mild stroke.

Factors associated with fatal outcome in posterior reversible encephalopathy syndrome: a retrospective analysis of the Berlin PRES study

Although often reversible, fatal outcome in posterior reversible encephalopathy syndrome (PRES) is well known. However, data on predictors of PRES-associated in-hospital death are scarce. In this study, we aimed to investigate predictors of in-hospital death in a large cohort. Radiological report databases between January 1999 and February 2015 were retrospectively searched for patients with PRES. Patients were included if they met criteria for PRES after detailed investigation of clinical charts and imaging studies. Various clinical, paraclinical and brain MRI data as well as data on in-hospital mortality were analyzed. 151 patients were included into the study, 64% were female. Seventeen (11.2%) patients died during hospital stay. In univariate analyses, higher age (p = 0.04), higher levels of C-reactive protein (p < 0.001), etiology of PRES (sepsis and chemotherapy; p = 0.02), altered coagulation (p = 0.002), altered mental state at onset (p = 0.03), and subarachnoid hemorrhage (SAH; p = 0.01) were related to in-hospital death. In multivariate analyses adjusted for age and sex, elevated CRP levels (OR 1.1 95% CI 1.1-1.2), altered coagulation (OR 5.1 95% CI 1.8-14.7), subarachnoid hemorrhage (OR 10.1 95% CI 2.2-46.1) and altered mental state (OR 3.3; 95% CI 1.1-9.4) were independently associated with in-hospital death. Altered mental state, subarachnoid hemorrhage as well as the higher levels of CRP and altered coagulation were significantly more frequent in patients who died in hospital. However, prospective studies are warranted to establish predictors of fatality in patients with PRES.

Posterior reversible encephalopathy syndrome in children: radiological and clinical findings - a retrospective analysis of a German tertiary care center

PURPOSE

To report the radiological and clinical spectrum of posterior reversible encephalopathy syndrome (PRES) in children in a German tertiary referral center.

METHODS

The radiological report data bases of the authors' university hospitals were searched for paediatric patients with PRES. Clinical and paraclinical data as well as various imaging features at symptom onset and during follow-up were tabulated in patients fulfilling the criteria for PRES.

RESULTS

A total of 18 paediatric patients with PRES were included into the study. Mean age was 9 years (IQR 7-12), 38.9% were females. Most frequent predisposing causes were renal and haemato-oncologic diseases frequently associated with endotheliotoxic cytostatic medication. Frontal lesions occurred as frequently as parietal lesions followed by occipital lesions. The superior frontal sulcus topographic lesion pattern occurred as frequent as the parieto-occipital one. In 38% of cases residual lesions were encountered with focal laminar necroses being most frequent. Initial clinical syndromes associated with PRES included seizures in 18, altered mental state in 5, and hemiparesis and visual disturbances in 2 children. Mean arterial blood pressure at onset of PRES was 140/85 mmHg (IQR systolic: 124-169, diastolic: 78-93 mmHg).

CONCLUSION

Paediatric PRES in this cohort comprises a broad radiological and clinical spectrum. The occurrence of frontal lesions, a superior frontal sulcus associated lesion pattern, and the development of focal laminar necrosis appear to be frequent in children.

Peripheral endothelial function and arterial stiffness in women with migraine with aura: a case-control study

BACKGROUND

Vascular dysfunction may be involved in migraine pathophysiology and contribute to the increased risk of ischemic stroke in migraine, particularly in women with migraine with aura (MA). However, data on endothelial function in MA are controversial. Here, we investigated whether systemic endothelial function and arterial stiffness are altered in women with MA, using a novel peripheral arterial tonometry device for the first time.

METHODS

Twenty-nine female MA patients without comorbidities and 30 healthy women were included, and carotid intima-media thickness was assessed by a standardized procedure. Endothelial function was assessed using peripheral arterial tonometry. Reactive hyperaemic response of digital pulse amplitude was measured following 5 minutes of forearm occlusion of the brachial artery. Arterial stiffness was assessed by fingertip tonometry derived and heart-rate-adjusted augmentation index.

RESULTS

No differences were found in peripheral arterial tonometry ratio (2.3 ± 0.6 vs 2.2 ± 0.8; p = 0.58) and left carotid intima-media thickness (in µm: 484 ± 119 vs 508 ± 60; p = 0.37). Women with MA had higher heart-rate-averaged augmentation index [median (interquartile range, IQR) of 5 (IQR 0.5 to 18) vs -5 (IQR -16.8 to 8.3), p = 0.005] and heart-rate-adjusted augmentation index [1 (IQR -6 to 12.5) vs -8 (IQR -20.3 to 2.5), p = 0.008] than healthy controls.

CONCLUSION

Peripheral endothelial function is not impaired in women with MA, but they have greater arterial stiffness. This may contribute to the increased stroke risk in women with MA.

New vessels after stroke: postischemic neovascularization and regeneration

The formation of new blood vessels after acute ischemic stroke is one of the most promising approaches to future therapies in the emerging field of stroke medicine. Angiogenesis and postnatal vasculogenesis are the underlying mechanisms of the formation of new blood vessels. Bone marrow-derived endothelial progenitor cells (EPCs) are thought to play an important role in neovascularization and during the regenerative processes after a vascular injury as well as in the maintenance of endothelial integrity. This review summarizes possible mechanisms of angiogenesis, postischemic neovascularization and regeneration with a focus on the potential role of EPCs as a risk marker and as a therapeutic target in stroke medicine.

Changes in cognitive function over 3 years after first-ever stroke and predictors of cognitive impairment and long-term cognitive stability: the Erlangen Stroke Project

BACKGROUND AND PURPOSE

Cognitive impairment (CI) is frequent after stroke, but data from population-based stroke cohorts on the natural course of CI are limited. The purpose of this study was to determine changes in cognitive status over 3 years after stroke.

METHODS

Data were collected from the Erlangen Stroke Project, an ongoing population-based stroke registry. The Mini-Mental State Examination (MMSE) for assessing global cognitive function was used; CI was defined as an MMSE score <24.

RESULTS

From February 1998 to January 2006, 630 patients with first-ever stroke were included. Prevalence rates of CI at 3 months, 1 and 3 years were 15, 13, and 12%. In multivariable analysis, stroke severity, i.e. Barthel index (p < 0.001), age (OR = 1.03; 95% CI = 1.00-1.05) and diabetes mellitus (OR = 2.03; 95% CI = 1.13-3.67) were associated with CI at 3 months. Recovery rate from CI at 3 months after stroke was found to be 31% over the following 3 years. Intact cognitive function rate was 71% over 3 years and inversely associated with age (OR = 0.96; 95% CI = 0.96-0.94) and stroke severity (p < 0.001).

CONCLUSION

CI is frequent among stroke survivors and associated with age, stroke severity, and diabetes mellitus, but recovery occurs in approximately one third of the patients over the course of 3 years. Factors affecting intact cognitive function over time are increasing age and stroke severity.