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A Resposta Inflamatória Sistémica está ligada com a Severidade do Edema Cerebral e Deterioração Neurológica após Recanalização em AVC isquémico
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Title:
A Resposta Inflamatória Sistémica está ligada com a Severidade do Edema Cerebral e Deterioração Neurológica após Recanalização em AVC isquémico
Author:
Joana Isabel Afonso Neto
Subjects:
Ciências médicas e da saúde
;
Clinical medicine
;
Medical and Health sciences
;
Medicina clínica
Description:
Introdução e Objetivos: Os mecanismos pelos quais a inflamação sistémica piora o outcome clínico no acidente vascular cerebral isquémico ainda estão por explorar. A nossa hipótese é a de que a resposta inflamatória sistémica aumenta o edema cerebral (CED) dificultando a recuperação neurológica. Métodos: Analisámos doentes seriados submetidos a trombólise intravenosa (IVT) ou trombectomia endovascular (EVT) entre 2017 e 2018 e determinámos o Rácio Neutrófilo- Linfócito (NLR), Plaqueta-Linfócito (PLR) e a presença de Síndrome de Resposta Inflamatória Sistémica (SIRS) nestes doentes. O CED foi classificado através da definição do European Cooperative Acute Stroke Study (ECASS)-2, usando a TC-cerebral às 24 horas. Os outcomes clínicos incluídos foram a deterioração neurológica precoce (END) e a dependência funcional a 90 dias. Os outcomes foram avaliados através de regressão ordinal e logística. As áreas sob as curvas ROC foram usadas para encontrar os melhores valores de cut-off das variáveis contínuas para prever os outcomes. Resultados: Incluímos 376 doentes; 67% dos doentes receberam IVT e 61% receberam EVT. Valores aumentados de NLR depois de recanalização foram associados a CED mais severo às 24 horas (Odds Ratio Ajustado (aOR)=1.47, Intervalo de Confiança a 95% (CI)=1.18 - 1.82, p<0.01). Além disso, o NLR esteve também significativamente associado a END (aOR=1.61, CI=1.09 - 2.38, p<0.05) e a pior prognóstico funcional a 90 dias (aOR=1.60, CI=1.24 - 2.07, p<0.01). O PLR mostrou associação similar, mas o NLR >6.2 foi o preditor de CED e outcome clínico mais fiável (AUC ~0.7, p<0.01), mesmo após ajuste para as características basais e excluindo casos de transformação hemorrágica significativa. O SIRS associou-se à severidade do CED, mas não se associou ao outcome clínico. Conclusões: A inflamação periférica precoce após revascularização está associada ao aumento da severidade do CED, END e, no limite pior outcome funcional. Assim, índices inflamatórios mais facilmente acessíveis, como o NLR, podem ser úteis para estratificação de doentes para no futuro terapias com imunomodulação. Background and Purpose: The mechanisms by which systemic inflammation worsens clinical outcome in ischemic stroke have not been still well explored. We hypothesized that the peripheral inflammatory response augments cerebral edema (CED) and it ultimately impends neurological recovery. Methods: We analyzed consecutive patients with ischemic stroke of the anterior circulation submitted to intravenous thrombolysis (IVT) or endovascular treatment (EVT) during 2017 and 2018. We determined neutrophil-(NLR) and platelet-to-lymphocyte (PLR) ratios and the presence of Systemic Inflammatory Response Syndrome (SIRS). CED degrees were classified using the European Cooperative Acute Stroke Study (ECASS)-2 definition on CT scan at 24 hours. The clinical outcomes included early neurological deterioration (END) and functional dependence at 90 days. Ordinal and logistic regressions were used to predict the outcomes. Area Under the Curve (AUC) of Receiver Operating Characteristic curves were used to find the best cut-off values on continuous variables to predict outcomes. Results: We included 376 patients; 67% received IVT and 61% EVT. Increasing values of NLR after recanalization were associated with higher degree of CED at 24 hours (adjusted odds ratio (aOR)=1.47, 95% Confidence Interval (CI)=1.18 - 1.82, p<0.01). Moreover, NLR was also significantly associated with END (aOR=1.61, CI=1.09 - 2.38, p<0.05) and poor functional status at 90 days (aOR=1.60, CI=1.24 - 2.07, p<0.01). PLR showed similar association but NLR >6.2 was the most accurate predictor of CED and clinical outcome (AUC ~0.7, p<0.01), even after adjustment to baseline severity and excluding cases of significant hemorrhagic transformation. SIRS was associated CED severity but not clinical outcome. Conclusions: Peripheral inflammation early after recanalization is associated with increasing severity of CED, neurological deterioration and ultimately, poor functional outcome. Easily assessable pro-inflammatory indexes could be useful for patient stratification for future immunomodulation therapies.
Creation Date:
2020
Language:
English
Source:
Universidade do Porto Institutional Repository Open Access
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