Study on the correlation between serum indole-3-propionic acid levels and the progression and prognosis of acute ischemic stroke

OBJECTIVE

This study aimed to explore the correlation between the serum level of indole-3-propionic acid (IPA) and the progression and prognosis of acute cerebral infarction (ACI).

METHODS

This study enrolled 197 patients with ACI, and 53 participants from a community-based stroke screening program during the same period were included as the control group. The patients with ACI were divided into quartiles of serum IPA. A logistic regression model was used for comparison. Receiver operating characteristic (ROC) curves were drawn to evaluate the predictive value of the IPA.

RESULTS

Compared with the healthy control group, the ACI group had lower serum IPA (P < 0.05). The serum IPA was an independent factor for acute ischemic stroke (OR=0.992, 95% CI: 0.984-0.999, P=0.035). The serum IPA was lower in patients with progressive stroke or poor prognosis than in patients with stable stroke or good prognosis (P < 0.05). Patients with ACI with low serum IPA are prone to progression and poor prognosis. The best cutoff value for predicting progression was 193.62 pg/mL (sensitivity, 67.5%; specificity 83.7%), and that for poor prognosis was 193.77 pg/mL (sensitivity, 71.1%; specificity, 72.5%).

CONCLUSION

The serum level of IPA was an independent predictor of ACI and had certain clinical value for predicting stroke progression and prognosis in patients with ACI.

Ketamine-induced prevention of SD-associated late infarct progression in experimental ischemia

Spreading depolarizations (SDs) occur frequently in patients with malignant hemispheric stroke. In animal-based experiments, SDs have been shown to cause secondary neuronal damage and infarct expansion during the initial period of infarct progression. In contrast, the influence of SDs during the delayed period is not well characterized yet. Here, we analyzed the impact of SDs in the delayed phase after cerebral ischemia and the potential protective effect of ketamine. Focal ischemia was induced by distal occlusion of the left middle cerebral artery in C57BL6/J mice. 24 h after occlusion, SDs were measured using electrocorticography and laser-speckle imaging in three different study groups: control group without SD induction, SD induction with potassium chloride, and SD induction with potassium chloride and ketamine administration. Infarct progression was evaluated by sequential MRI scans. 24 h after occlusion, we observed spontaneous SDs with a rate of 0.33 SDs/hour which increased during potassium chloride application (3.37 SDs/hour). The analysis of the neurovascular coupling revealed prolonged hypoemic and hyperemic responses in this group. Stroke volume increased even 24 h after stroke onset in the SD-group. Ketamine treatment caused a lesser pronounced hypoemic response and prevented infarct growth in the delayed phase after experimental ischemia. Induction of SDs with potassium chloride was significantly associated with stroke progression even 24 h after stroke onset. Therefore, SD might be a significant contributor to delayed stroke progression. Ketamine might be a possible drug to prevent SD-induced delayed stroke progression.

How to Define Fast and Slow Progressors in Any-Type Occlusion Acute Ischemic Stroke

The variable rate of infarct progression in acute ischemic stroke as assessed by various thresholds excludes a substantial proportion of patients due to time or core constraints. We evaluated 106 patients with any-type occlusion to compare these thresholds and assessed performance of hypoperfusion index (HI) for fast and slow rate of infarct progression. Seven (12.5%) were classified fast progressors and 23 (46%), 25 (50%), 12 (24%), and 33 (66%) slow progressors using different core and time criteria. In comparison, HI categorized 100% (n = 106) of cohort with optimal cutoff 0.5 for any-type occlusion (slow progressors: HI ≤ 0.5), sensitivity/specificity 100%/91%, AUC 0.94, and indicative of eligibility for reperfusion and clinical outcomes (median 90-day modified Rankin Scale; 2 for HI ≤ 0.5 versus 5). Estimation of progressors by HI seems comprehensive but needs external validation.

The clinical value of serum xanthine oxidase levels in patients with acute ischemic stroke

Xanthine oxidase (XO), a form of xanthine oxidoreductase, is widely distributed in various human tissues. As a major source for the generation of superoxide radicals, XO is involved in the induction of oxidative stress and inflammation during ischemic and hypoxic tissue injury. Therefore, we designed this study to identify the role of serum XO levels in acute ischemic stroke (AIS) pathogenesis. In this single-center prospective study, 328 consecutive patients with AIS for the first time were included, and 107 age- and sex-matched healthy controls from a community-based stroke screening population were also included. The serum levels of XO and several conventional stroke risk factors were assessed. Multivariate analysis was applied to evaluate the relationship between serum levels of XO and clinical outcomes, and nomogram models were developed to predict the onset, progression and prognosis of AIS. Compared with the healthy control group, the serum level of XO was significantly higher in the AIS group (P < 0.05) and was an independent risk factor for AIS (OR 8.68, 95% CI 4.62-14.33, P < 0.05). Patients with progressive stroke or a poor prognosis had a much higher serum level of XO than patients with stable stroke or a good prognosis (all P < 0.05). In addition, the serum level of XO was an independent risk factor for stroke progression (OR 1.98, 95% CI 1.12-3.50, P = 0.018) and a poor prognosis (OR 2.51, 95% CI 1.47-3.31, P = 0.001). The nomogram models including XO to predict the onset, progression and prognosis of AIS had good prediction and differentiation abilities. The findings of this study show that the serum level of XO on admission was an independent risk factor for AIS and had certain clinical predictive value for stroke progression and prognosis in patients with AIS.

Frequency, management, and outcomes of early neurologic deterioration due to stroke progression or recurrence

OBJECTIVE

The frequency, management, and outcomes of early neurologic deterioration (END) after ischemic stroke specifically due to stroke progression or stroke recurrence have not been well delineated.

MATERIALS AND METHODS

In a multicenter, nationwide registry, data on END due to stroke progression or recurrence confirmed by imaging were collected prospectively between January 2019 and July 2020. Patient characteristics, management strategies, and clinical outcomes were analyzed.

RESULTS

Among 14,828 consecutive ischemic stroke patients, 1717 (11.6%) experienced END, including 1221 (8.2%) with END due to stroke progression (SP) or stroke recurrence (SR). Active management after END was implemented in 64.2% of patients. Active management strategies included volume expansion (29.2%), change in antithrombotic regimen (26.1%), induced hypertension (8.6%), rescue reperfusion therapy (6.8%), intracranial pressure lowering with hyperosmolar agents (1.5%), bypass surgery (0.6%), and hypothermia (0.1%). Active management strategies that varied with patient features included volume expansion and induced hypertension, used more often in large artery atherosclerosis and small vessel occlusion, and rescue endovascular thrombectomy, more common in other (dissection), cardioembolism, and large artery atherosclerosis. Active management was associated with higher rates of freedom from disability (modified Rankin Scale, mRS, 0-1; 24.3% vs. 16.6%) and functional independence (mRS, 0-2; 41.6% vs. 27.7%) at 3 months.

CONCLUSION

END specifically due to stroke progression or recurrence occurs in 1 in 12 acute ischemic stroke patients. In this observational study, active management, undertaken in two-thirds of patients, was most often hemodynamic or antithrombotic and was associated with improved functional outcomes.

Predictors of Poor Outcome in Patients with Minor Ischemic Stroke by Using Magnetic Resonance Imaging

Although the symptoms of minor ischemic stroke are mild, poor prognosis may occur if left untreated. Therefore, it is particularly important to identify the predictors that associated with poor outcome in patients presenting minor ischemic stroke. The aim of this study was to elucidate the predictors of progression by using magnetic resonance imaging (MRI). A total of 516 patients diagnosed with minor ischemic stroke were enrolled in this study. They were divided into two groups, the progressive group and non-progressive group, according to the modified Rankin Scale (mRS) with the cutoff value of 2 points on day 90 after the stroke onset. We compared the results of MRI scan between the two groups to investigate the potential independent determinants of progression using multivariate logistic regression analysis. Ninety of 516 patients (17.44%) underwent progression. There were 9 factors that were independently associated with poor outcome, including age (OR = 1.045, 95% CI 1.017-1.074), heart disease (OR = 2.021, 95% CI 1.063-3.841), baseline NIHSS score (OR = 1.662, 95% CI 1.177-2.347), limb motor disturbance (OR = 2.430, 95% CI 1.010-5.850), ataxia (OR = 2.929, 95% CI 1.188-7.221), early neurological deterioration (OR = 50.994, 95% CI 17.659-147.258), diameter of infarction (OR = 1.279, 95% CI 1.075-1.521), non-responsible vessel size (OR = 2.518, 95% CI 1.145-5.536), and large-artery atherosclerosis (OR = 2.010, 95% CI 1.009-4.003). This study indicated that age, heart disease, motor disturbance of limb, ataxia, early neurological deterioration, diameter of infarction, size of non-responsible vessels, and large-artery atherosclerosis can be used to assess the prognosis of patients with minor ischemic stroke.

Association of initial infarct extent and progressive motor deficits in striatocapsular infarction

BACKGROUND AND PURPOSE

Progression of motor deficits in the acute period is frequently observed in patients with subcortical striatocapsular infarctions. Therefore, we sought to determine the factors associated with early motor progression in patients with infarcts confined to the striatocapsular region.

METHODS

We studied 80 consecutive patients with striatocapsular-region infarction, as defined by clinical and MRI criteria, within 24 hours after stroke onset. Motor progression was defined as an increase of >2 points in the motor items of the National Institutes of Health Stroke Scale (NIHSS) within 7 days of stroke onset. The study population was divided into patients with and without motor progression, and risk factors, clinical features, and brain MRI/magnetic resonance angiograpy (MRA) findings were compared between these groups.

RESULTS

Motor progression was observed in 40% of the 80 patients. The independent variables associated with motor progression were a history of hypertension (OR=7.8, 95% CI=1.5-39.8, p=0.013) and an initial infarct extent of >/=15 mm (OR=9.2, 95% CI=1.8-45.7, p=0.006). However, there were no differences in the initial NIHSS score, other stroke risk factors, vascular stenosis pattern, or cardioembolic source.

CONCLUSIONS

Early motor progression in patients with striatocapsular-region infarction is associated with the initial extent of the lesion. However, the stroke mechanism and vascular stenosis did not differ between the motor progression and stable groups.