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THE DYNAMICS OF SERUM INFLAMMATORY MARKERS IN SUBACUTE STROKE AND ASSOCIATIONS WITH AEROBIC FITNESS TRAINING AND CLINICAL OUTCOME: RESULTS OF THE RANDOMIZED CONTROLLED PHYS-STROKE TRIAL
Background and Aims
Inflammatory markers are upregulated following stroke. Inflammatory activity after stroke is associated with increased mortality, recurrent vascular risk, and impaired outcome. However, dynamics of inflammatory markers in subacute stroke phases remain unclear. Physical fitness training may play a role in decreasing long-term inflammatory activity after stroke. Aims: To investigate the dynamics of hs-CRP, IL-6, TNF-alpha and fibrinogen in subacute to chronic stroke and to determine whether serum levels are modified by exposure to an early fitness training intervention and associated with functional recovery at follow-up.
This is an exploratory analysis of patients enrolled in the multicenter randomized-controlled PHYS-STROKE trial. Patients with subacute stroke (day 5-45) and standard rehabilitative therapy were randomized to receive either four weeks of aerobic fitness training or relaxation sessions. GEE-Models were used to investigate the dynamics of inflammatory markers and associations of aerobic fitness training with inflammatory markers over time. Using multiple logistic regression models, we analyzed associations between inflammatory marker levels and functional outcome (measured by mRS or BI) up to six months after stroke.
Hs-CRP, IL-6, and fibrinogen levels declined significantly over time (p all ≤ 0.01). Exposure to aerobic fitness training did not influence levels of inflammatory markers at follow-up. Elevated baseline IL-6 and fibrinogen levels were independently associated with worse functional outcome parameters up until six months.
Elevated serum inflammatory markers gradually decrease after stroke. Increased IL-6 and fibrinogen in early and late subacute stroke phases are associated with impaired functional outcome up to six-months after stroke.
COMBINING TWO RELATED DNA BIOMARKERS TO STRATIFY PATIENTS FOR PRECISE MEDICINE IN STROKE
Background and Aims
CpG-enriched extracellular DNA (exDNA) fragments in plasma belong to signal molecules that bind TLR9 to activate NFkB-mediated inflammaton. Genetic polymorphism of TLR9, the exDNA receptor, associates with multiple organ failure developments and lethal outcomes of post-trauma and sepsis patients. We hypothesize that the genetic variant of TLR9 (rs352162), linked to better proinflammatory signaling in response to DNA ligand, predisposes most to the unfavorable course and outcome of stroke in a cohort of patients exhibiting an increased concentration of exDNA in circulation. Thus, the study aimed to assess whether combining the TLR9 genetic marker and determining the exDNA concentration may better select a cohort of patients in whom exDNA-receptor signaling contributes most to the course of a stroke.
ExDNA was isolated from plasma of 138 patients with stroke using organic solvents, and SYBR Green determined the concentration. Genotyping of allelic variants of the TLR9 rs352162 gene was performed using a PCR and designed allele-specific tetra primers followed by electrophoretic separation of the products. Statistical significance between groups of patients was performed by the t-test, Fisher test, Mann-Whitney test, and One-way ANOVA.
TLR9 CC carriers exhibited a more severe course of the disease. ExDNA >300 ng/ml associated with increased odds ratio values for infection and 30-day lethality in TLR9 CC-positive stroke patients versus patients with TLR9 CT and TT genotypes (OR=63 vs. OR=6,145, P<0.001 and P=0.007, respectively).
Determining both exDNA concentration and TLR9 genetic polymorphism might aid in selecting patients who may benefit most from inhibitingTLR9 signaling and /or exDNA extracorporeal sorption.
LVO-CHECK: A RAPID POINT-OF-CARE BLOOD TEST TO REFER LVO PATIENTS FROM THE AMBULANCE TO THE THROMBECTOMY CENTER
Background and Aims
Several tools such as clinical scales or individual blood biomarkers are being used to identify LVO patients out of the hospital and shift them directly to thrombectomy centers. However, their accuracy is suboptimal. We aimed to validate a new panel of blood biomarkers in a rapid Point-of-Care (POCT) format to be used to triage LVO patients.
Patients with suspected stroke (< 6h) were enrolled (n=197) and blood samples collected at ED. A 10 biomarkers panel was measured by immunoassays to select combinations of biomarkers associated with LVO. Best final candidates with available commercial POCTs were FABP/NT-proBNP in combination with simple clinical data (age, NIHSS, etc). Those results were prospectively replicated in BIO-FAST study that recruited n=300 patients with stroke suspicion onset < 6h in an ambulance network serving two thrombectomy centers (Biomarkers for Initiating Onsite and Faster Ambulance Stroke Therapies, ClinicalTrials.gov identifier: NCT04612218).
Median NIHSS =7 (3-15), ASPECTS =10 (9-10) and blood samples obtention since stroke onset =2.16 hours (1.08, 5.25). Final diagnosis percentage was ischemic stroke (65.9%), hemorrhagic stroke (17.0%) and mimics (17.0%). Of the whole cohort 34.1% fulfilled LVO strict definition. LVO-check was 95% specific and 70% sensitive for LVO. Even using more simple scales such as Cincinnati instead of NIHSS the test showed good accuracy (100% specificity & 50% sensitivity).
LVO check is a rapid (10´) blood test that with a very high specificity and high sensitivity might allow referring LVO patients to thrombectomy centers or even attempting direct shift to the angio-suite.