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July2011 Vol.48 Issue:      3 (Supp.) Table of Contents
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Prognostic Value of D-Dimer in Diffusion Weighted-MRI Defined Early Ischemic Stroke Recurrence

Alaa A.M. Abdel Ghani1, Ashraf M. Zaitoun1, Heba Hassan Gawish2, Mohamad H. Abo Warda3

 

Departments of Neurology1, Clinical Pathology2, Radiology3, Zagazig University; Egypt

 



ABSTRACT

Background: The identification of factors associated with early stroke recurrence is of great importance to establish effective treatment for secondary stroke prevention. Objective: Study of D-dimer in diffusion weighted-MRI defined early ischemic stroke recurrence. Methods: This study was carried out on 50 acute ischemic stroke patients, 33 males and 17 females, with ages ranging from 20-80years. All patients were subjected to full history taking, complete general and neurological examination and laboratory investigations including routine laboratory investigations and plasma levels of hemostatic biomarkers within the first 24 hours of symptom onset. Diffusion weighted- magnetic resonance imaging (DW-MRI) was performed to all patients on admission and after five days. Results: Early recurrent ischemic lesions (ERILs) were detected in 15(30%) of our patients. Atherosclerotic subtype of stroke was more associated with ERILs, while lacunar subtype was more in patients without ERILIs. A statistically significant difference was found between the two groups regarding the infarcts volume, acute multiple infarcts on initial DW-MRI and the onset to initial DW-MRI (P<0.05). Of the laboratory findings, only D-dimer results were highly statistically significant between patients with and those without ERILs (P<0.001). It was highest in stroke patients with other or undetermined etiology and cardio-embolic stroke followed by atherosclerotic and lacunar subtypes. There was a highly statistically significant difference regarding the level of D-dimer in relation to the number and volume of infarcts on initial DW-MRI (P<0.001). Based on logistic regression analysis, D-dimer and atherosclerosis were found to be significant predictors of ERILs. Conclusion: Measurement of D-dimer, which is cheep and widely available, independently predicts progressing ischemic stroke and may also be helpful in selecting  patients who could benefit from measures taken to prevent early neurologic deterioration after ischemic stroke. [Egypt J Neurol Psychiat Neurosurg.  2011; 48(3): 215-222]

 

Key words: Prognostic, D-dimer, Diffusion weighted-MRI, Ischemic stroke, Recurrence.

 

Correspondence to Alaa Abdel Ghani, Neurology Department, Zagazig university, Egypt,

Tel.: +20123006744      E-mail: alaa_abdelghani@hotmail.com.





INTRODUCTION

 

Early neurological deterioration occurs during the acute phase in approximately one third of all ischemic stroke patients and is associated with a significantly greater morbidity and mortality1.

Because the risk of recurrent stroke is highest in the first few months after stroke, the identification of factors associated with early recurrence is of great importance to established effective treatments for the secondary stroke prevention2.

Previous studies have shown that the evidence of early recurrence on MRI is much more frequent than clinical recurrent stroke within the first week and up to one to three months after an index stroke3. Recurrence on MRI, although mostly clinically silent, has been suggested as a potential surrogate marker for clinical recurrence of stroke, because these silent lesions were associated with subsequent clinical recurrent ischemic stroke, i.e. MRI may depict pathological changes before the development of clinical stroke syndromes4.

 

The measurement of biomarkers indicating the presence of coagulation activation might offer additional risk assessment beyond that of clinical factors alone. One candidate marker is D-dimer, a fibrin degradation product released into the blood stream by fibrinolysis of cross-linked fibrin and indicating the presence of active thrombus formation and lysis5. Highly elevated D-dimer values are observed in various disorders in which the coagulation system is excessively activated, such as acute venous thromboembolism6 and Coronary heart disease7,8. D-dimer has also shown to predict early clinical progression in ischemic stroke9. D-dimer levels among patients who met the criteria for a progressing stroke were significantly higher than those with no progression10.

The present work was carried out to study the prognostic value of D-dimer in  patients with early recurrent ischemic lesions (ERILs) as defined by DW-MRI.

 

PATIENTS AND METHODS

 

Our present study was carried out on 50 acute ischemic stroke patients 33 males and 17 females, with ages ranging from 20-80 years (mean±SD = 60.6±8.1), selected from Intensive Care Unit and Stroke Unit, Neurology Department, Zagazig University Hospitals.

Patients were excluded if any of the following criteria were met: age younger than 20 years, a delay more than 24 hours from symptoms onset to admission, severe coma or terminal illness, epileptic seizure activity and patients receiving anticoagulants before admission.

 

All patients were subjected to:

1)      Thorough neurological history.

2)      Complete general and neurological examination.

3)      Assessment of stroke severity using the National Institute of Health Stroke Scale Score (NIHSS) at admission11.

4)      Clinical classification according to Oxofordshire Community Stroke Project (OCSP) classification12.

5)      Follow up within the first week after admission, progressing stroke was defined clinically using a modification of the European Progressing Stroke Study(EPSS) criteria13. This requires deterioration in conscious level, arm or leg weakness, or speech over 72 hours following admission.

6)            Laboratory investigations:

i-       Routine laboratory investigations (CBC, blood glucose, liver and renal function tests, ESR and lipid profile).

ii-      Plasma levels of hemostatic biomarkers( fibrinogen, D-dimer and high sensitivity C-reactive protein), within the first 24 hours of symptom onset. Blood was withdrawn before the initiation of any oral, enteral or parenteral feeding or medications. Plasma or serum was immediately separated and samples were analyzed within 4 hours or stored at -80°C until analysis. Biomarkers were measured with the following methods: high sensitivity C-reactive protein with turbidimory (COBAS INTEGRA 700; Roche GmbH, Maannheim, Germany), fibrinogen with class method (SAT fibrinogen; diagnostica STGO, Asnieres, France), D-dimer with turbidimetry (SAT Liatest D-Di; Diagnostica STAGO) on the STAgo compact analyzer (Diagnostica STAGO). There was no change in the instrumentation or control results during the study period.

7)            Radiological investigations:

         Diffusion weighted- magnetic resonance imaging (DW-MRI) was performed to all patients on admission and at five days after onset. Early recurrent ischemic lesions (ERILs) were defined as new lesions on follow up DW-MRI outside the region of the acutely symptomatic (index) lesion and which was not detected on initial DW-MRI. Enlargement of an initial DW-MRI lesion was not considered ERIL, as they may represent fragmentation of the initial embolus rather than recurrent ischemic events14. The presence of ERILs was determined by slice to slice comparison of initial and follow up DW-MRIs. Ischemic lesion volume was measured as infarct volume (ml) = the sum of infracted area on each DW-MRI slice x (slice thickness + interslice gap).

 

Statistical Analysis:

Statistical analysis was performed using software package S.P.S.S 13 to calculate basic statistical parameters . Chi-square, ANOVA and student t- test were used for comparisons. Logistic  regression analysis was performed among the parameters to identify the independent predictors of early recurrent ischemic lesions. Statistical significance was considered to be indicated by a value of P<0.05 and  p <0.001 was considered as highly statistically significant.

 

RESULTS

 

This study was carried out on 50 stroke patients, who had acute infarcts on initial DW-MRI within 24 hours of onset; after exclusion of patients who did not meet the inclusion criteria, patients admitted during the night or at holidays, due to unavailability of plasma or serum collection, and patients who refused to participate in the study, their ages ranged from 20 to 80 years (mean 60.6±8.1). They were 33 males and 17 females. Fifteen patients(30%) had early recurrent ischemic lesion (ERILs) and 35 patients had no ERILS. There was no statistically significant difference between patients with ERILs and patients without ERILs regarding age, sex, risk factors, stroke laterality, national institute of health stroke score scale (NIHSS) and medications received. A statistically significant difference was found only between atherosclerotic and lacunar subtypes of ischemic stroke in those with ERILs and those without ERILs( Atherosclerotic subtype was more found with ERILs, while lacunar subtype was more in patients without ERILIs)  (Table 1).

Diffusion weighted-Magnetic resonance imaging (DW-MRI) findings between patients with ERILs and those without ERILs were demonstrated in table (2). There was a statistically significant difference between the two groups regarding the infarcts volume, acute multiple infarcts on initial DW-MRI and the onset to  initial DW-MRI; whereas there was no statistically significant difference regarding the time from onset to follow up DW-MRI.

Of the laboratory findings in the two groups, only D-dimer results were highly statistically significant between patients with and those without ERILs (Table 3). The level of D-dimer was different according to the stroke subtypes. It was highest in stroke patients with other or undetermined etiology and cardio-embolic stroke followed by atherosclerotic and lacunar infarction (table 4). There was a highly statistically significant difference regarding the level of D-dimer in relation to the number of infarctions on initial DW-MRI (Table 5), and the level of D-dimer in relation to the infarct volume on initial DW-MRI (Table 6).

Based on logistic regression analysis, D-dimer, atherosclerosis and acute multiple infarcts were found to be significant predictors of early recurrent ischemic lesions in our patients (Table 7).


 

Table 1. Demographic data and clinical characteristics of patients with and without ERILs.

 

Clinical characteristics

Patients with ERILs (n=15)

Patients without ERILs (n=35)

P

Age (years) (M±SD)

50.6±8.1

58.9±6.9

0.45

Sex (males/females)

9/6

24/11

0.55

Risk factors:

 

 

 

               - Hypertension

10

28

0.47

               - Diabetes mellitus

5

10

0.74

               - Smoking

6

11

0.55

               - Previous stroke ± TIAs

5

9

0.73

               - Dyslipidemia

7

16

0.95

Stroke laterality

 

 

 

               - Left hemisphere

5

20

0.12

               - Right hemisphere

10

15

0.12

Ischemic stroke subtypes

 

 

 

               - Cardio-embolic (10)

5

5

0.14

               - Atherosclerotic (21)

10

11

0.02*

               - Lacunar (17)

2

15

0.04*

               - Others (2)

1

1

0.51

NIHSS

4

4

0.21

Medications

 

 

 

               - Anticoagulants

7

9

0.19

               - Antiplatelets

7

24

0.14

               - Non

1

2

1.0

* Significant at p<0.05

 

Table 2. DW-MRI findings in patients with and without ERILs.

 

DW-MRI findings

Patients with ERILs  (n=15)

Patients without ERILs (n=35)

P

- Infarct volume (ml)

2.5 (0.8-6.9)

0.8 (0.4-2.5)

<0.001*

- Acute multiple infarcts on initial DW-MRI

9

4

<0.001*

- Onset to initial DW-MRI (hours)

8.5 (4.2-13.8)

13.2 (8.5-17.2)

0.002*

-Onset to follow up DW-MRI (days)

4.8 (4.2-5.1)

4.5 (4.1-5.0)

0.100

* Significant at p<0.01

 

Table 3. Laboratory findings in patients with and without ERILs.

 

Laboratory test

Patients with ERILs (n=15)

Patients without ERILs (n=35)

P

- C-reactive protein (mg/dl)

2.6 (0.05-5.98)

3.4 (1.09-4.9)

0.080

- Fibrinogen (mg/dl)

328 (250-365)

303 (254-360)

0.170

- D-dimer (ng/ml)

850 (350-1200)

430 (215-950)

<0.001*

* Significant at p<0.01

Table 4. D-dimer levels in different stroke subtypes.

 

 

Cardio-embolic

Athero-sclerotic

Lacunar

Other

P

D-dimer level (ng/dl), mean

820

(320-1980)

480

(215-970)

320

(230-670)

840

(310-1020)

<0.001*

* Significant at p<0.01

 

Table 5. D-dimer in relation to number of infarcts on initial DW-MRI.

 

 

Patients with multiple infarcts

Patients without multiple infarcts

P

D-dimer level (ng/dl), mean

720

(20-1120)

450

(210-970)

<0.001*

* Significant at p<0.01

 

Table 6. D-dimer in relation to the volume of infarction on initial DW-MRI.

 

 

Patients with large infarct value

Patients with small infarct value

P

D-dimer level (ng/dl), mean

810

(250-1200)

430

(230-900)

<0.001*

* Significant at p<0.01

 

Table 7. Predictors of EIRLs based on multiple logistic regression analysis.

 

 

OR (95% CI)

P

D-dimer

2.0 (1.05-3.83)

0.02*

Atherosclerosis

2.45 (1.29-4.68)

0.003*

Infarction volume

1.69 (0.88-3.25)

0.09

Onset to initial DW-MRI

1.62 (0.84-3.12)

0.12

Acute multiple infarction

2.66 (1.4-5.07)

0.001**

* Significant at p<0.05 ** Significant at p<0.01

 


DISCUSSION

 

Early stroke recurrence after index stroke was reported to aggravate the case fatality rate, disability and prognosis of stroke15.

In our study, early recurrent ischemic lesions(ERILs) were detected in 15(30%) of our patients. This is approximate to that of  Kim et al.16, Kang et al.3,4,17,  and Barbar et al.10, who found that ERILs were detected in 28%, 25,5%, 35%,  34% and 25% of their patients respectively. However, higher results were reported by Kang et al.18 (47.4%) and lower results were reported in the study of Weimar et al.19 (13%), Moroney et al.20 (7.4%), Coutts et al.21 (9.8%) and Petty et al.22 (2%).

The variations in the recurrence rates in different studies might be explained not only by the differences in the study design or the studied population, but also by differences in the definition of recurrent stroke. Previous studies defined recurrent stroke as a new deficit that occurred only is a different anatomic or vascular territory or that was of a different subtype from that of index stroke20,23. However, MRI-defined ischemic lesion recurrence may provide a more sensitive and objective index of stroke recurrence21.

Regarding demographic and clinical data of our studied patients, we found no statistically significant difference between those with ERILs and those without ERILs, as regards age, sex, risk factors, stroke laterality, NIHSS and treatment received. However, a statistically significant difference was found only between atherosclerotic and lacunar subtypes of ischemic stroke (Atherosclerotic subtype was more associated with ERILs, while lacunar subtype was more in patients without ERILIs). This is in agreement with that of Kang et al.3, who reported that large artery atherosclerosis was the most common stroke subtype associated with ERILs. Toni et al.24 mentioned that except for a lower frequency of hypertension in their past medical history, improving patients presented a pattern of risk factors for stroke similar to that of non improving patients. However, Barber et al.10 found that patients with progressing stroke had older age, female gender, more admission neurological deficits, higher mean arterial blood pressure and more A.F. and Weimar et al.15 found that patient with neurological worsening had a worse neurological status on the NIHSS at hospital admission, more often a diagnosis of DM and more territorial and brain stem infarctions. However, these studies were aiming at study of progressive stroke being ERIL one of the causes  of progression.

Regarding diffusion weighted-MRI (DW-MRI) results among our patients, we found a statistically significant difference between patients with and those without ERILs, as regards infarct volume, infarcts number and the time from onset to initial DW-MRI, whereas, there was no statistically significant difference regarding the time from onset to follow up DW-MRI. Our results are in accordance with that of Kang et al.3, who mentioned that shorter time from onset to initial MRI, initial multiple infarcts, initial larger infarcts volume are associated with ERILs. In addition, Kim et al.12 stated that lesion growth and lesion recurrence are considered the two major types of changes in ischemic lesions on DW-MRI causing neurological deterioration after acute ischemic stroke. Kang et al.14 found that the baseline characteristics did not differ between patients with and patients without ERILs except that the frequency of multiple infarcts on initial DW-MRI that was significantly higher in patients with ERILs, and the time from onset to initial DW-MRI was shorter in patients with ERILs. Coutts et al.21, Wen et al.(25) and Kang et al.26 found that the number of baseline lesions on initial MRI was the only factor predictive of recurrent ischemic lesions in their studies. The same was also reported by Roquer et al.14, who found that patients with multiple DW-MRI lesions have a higher incidence of stroke recurrence than patients with single lesion.

Regarding the laboratory findings in our patients, we found that only D-dimer levels were highly statistically significant higher in patients with ERILs than in patients without ERILs and that the levels of D-dimer were different in different stroke subtypes (It was highest in patients with stroke of an undetermined etiology and stroke of cardio-embolic origin and lowest in lacunar subtybe). In addition, we found that the level of D-dimer was highly statistically significant related to the number and volume of infarcts on initial DW-MRI. These results are matching with that of Kang et al.3, who mentioned that the laboratory results except D-dimer did not differ between patients with and without ERILs, and that D-dimer and fibrinogen were positively correlated with the baseline infarct volume and number. They also found that the level of D-dimer was different according to the stroke subtypes (it was highest is stroke of undetermined etiology followed by cardio-embolic stroke). Barber et al.10 found that patients with progressing stroke had significantly elevated levels of prothrombin fragment 1+2, thrombin anti thrombin (TAT) complexes and fibrin D-dimer compared with patients with no progression. In addition, Barber et al.9 found that median D-dimer levels were higher in the progressing stroke group compared with the group with no progression. Ageno et al.27, found that D-dimer levels significantly differ among stroke subtypes after an acute ischemic event, as patients with cardio-embolic events had significantly higher levels than patients with different etiologic factors. Thrombus formation in the cardiac chambers is in most cases caused by blood stasis leading to a fibrin-rich clot very similar to venous thrombi but thrombus originating in the larger arteries are mostly platelet rich and fibrin formation is secondary to platelet activation. Also, Isenegger et al.28 concluded that low D-dimer levels in the few hours make a cardio embolic stroke unlikely and may be useful to guide further investigations. Fisher and Frances29 hypothesized that in subjects with lacunar infarcts, thrombi are too small to produce detectable elevation in plasma D-dimer levels. Another possibility is that a non thrombotic, lipohyalonotic degenerative process of the vessel wall is related to arterial hypertension or diabetes.

On the other hand, Krarup et al.30, concluded that D-dimer and other markers of hemostatic activation were not associated with stroke progression, recurrent stroke or death in patients with acute stroke and atrial fibrillation. Woodward et al.31 stated that D-dimer levels showed no relationship with recurrent stroke. Also, in a large series of patients by Di Napali et al.32, D-dimer levels were analyzed within the first 24 hours of stroke, and no significant differences were present in levels between stroke free survivors and patients who had a recurrent stroke.

The mechanism through which D-dimer levels are closely related to progressing stroke may be that increased D-dimer may reflect an ongoing thrombus formation within cerebral vessels or may be a marker of systemic hypercoagulability10. Furthermore, fibrin degradation products including D-dimer may act to stimulate the inflammatory process33,34 and this might provide a further pathological mechanism through which D-dimer is linked to progressing stroke35,36. There is some evidence that D-dimer itself stimulates monocyte synthesis and release of proinflammatory cytokines such as interleukin-6.36 This might provide a further pathomechanism through which D-dimer is linked to ERILs.  

On the other hand, it is possible that elevated D-dimer levels in patients with progressing stroke are simply a marker of a more severe stroke (as an acute phase reactants), bacterial infection (mainly chest and urinary tract) and venous thrombosis may be also other contributors. However, although these usually occur after the first week, these possibilities were minimized by withdrawing blood samples early after admission, and other recognized acute phase reactants (C-reactive protein, fibrinogen, WBCs) were included together with observation of fever.

In our study, D-dimer, atherosclerosis and initial acute multiple infarcts were found to be significant predictors of ERILs in our patient, based on logistic regression analysis. This is in accordance with that of Kang et al.3, who found that large artery atherosclerosis, D-dimer levels and initial acute multiple infarcts are independent predictors of ERILs. Barber et al.10, mentioned that D-dimer and mean arterial blood pressure remained independent predictors of progressing stroke. Also, Moroney et al.20, found that a major hemispheric stroke and atherothrombotic stroke mechanism were significant independent risk factors for early recurrence.

The limitations of our study is the small sample size and that our study can't exclude the possibility that elevated coagulation markers predated the acute event i.e. the patients may have had vascular disease before the stroke and are, therefore, likely to have increased pre stroke levels when compared with population controls.

 

Conclusion

In view of our results in the present study, we can conclude that measurement of D-dimer, which is cheep and widely available assay, independently predicts progressing ischemic stroke and provides a useful prognostic information. It may also be helpful in selecting patients who could benefit from measures taken to prevent early neurologic deterioration after ischemic stroke specially those taken to manipulate the coagulation system. However; Further larger and long term studies are recommended.

 

[Disclosure: Authors report no conflict of interest]

 

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الملخص العربى

 

القيمة التنبؤية للدي - دايمر في السكتة الدماغية الإحتشائية المترجعة مبكراً

المعرفة بواسطة الرنين المغناطيسي بالانتشار

 

            استهدف هذا البحث دراسة القيمة التنبؤية للدي - دايمر في مرضي السكتة الدماغية الإحتشائية المرتجعة مبكراً.

            قد أجري هذا البحث علي 50 مريضاً بالسكتة الدماغية الإحتشائية الحادة - تتراوح أعمارهم بين 20 - 80 سنة. وتم اختيارهم من مرضي وحدة السكتة الدماغية والعناية المركزة بقسم أمراض المخ والأعصاب بمستشفيات جامعة الزقازيق.

وقد خضع جميع المرضي إلي ما يلي:

-          التاريخ المرضي كاملاً.

-          الفحص الإكلينيكي العام والعصبي.

-          الفحوص المعملية الروتينية بالإضافة إلي قياس مستوي الدلالات الدموية في خلال الأربعة والعشرون ساعة الأولي من بداية المرض.

-          أشعة الرنين المغناطيسي بالانتشار عند دخول المريض وبعد خمسة أيام من دخوله.

            وقد وجدنا أن الرجوع المبكر لنقص الدم الموضعي للمخ قد حدث في 30% من المرضي. ووجد أنه كان أكثر حدوثا في الإحتشاء المخى الناتج من تصلب الشرايين بينما كان الإحتشاء الجوبي أكثر في المرضي الذين لم يعانون من الرجوع المبكر لنقص الدم الموضعي للمخ, كذلك وجد فرق إحصائي بين المجموعتين في حجم الإحتشاء المخى وعدده.

كما وجد أن نتائج الدي - دايمر كانت أعلي في مرضي المجموعة التي بها رجوع مبكر لنقص الدم الموضعي للمخ  عنه في المرضى الآخرين, وكانت كذلك أعلي في المرضي الذين لم يعرف سبب للإحتشاء المخى ومرض القلب عنه في الآخرين, وكذلك وجدت علاقة بين نتائج الدي - دايمر و عدد وحجم الإحتشاء المخي في الرنين المغناطيسي بالانتشار، كما وجد أن الدي-دايمر وتصلب الشرايين لهم قيمة تنبؤية في حالات الرجوع المبكر لنقص الدم الموضعي للمخ فى مرضى الإحتشاء المخي الحاد.

وقد إستنتجنا ضرورة قياس الدي - دايمر في حالات الإحتشاء المخي الحاد لما له من قيمة تنبؤية في حالات تدهور السكتة الدماغية الإحتشائية  وفي اختيار المرضي الذين يمكن أن يستفيدوا من القياسات التي تؤخذ لمنع الرجوع المبكر لنقص الدم الموضعي للمخ فى مرضى الإحتشاء المخي الحاد.



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