Open AccessBiomarkers in the Prediction of Hemorrhagic Transformation in Acute Stroke: A Systematic Review and Meta-Analysis
Author(s) -
S. Krishnamoorthy,
Gurpreet Singh,
Jithu Jose K,
Biju Soman,
Christian Foerch,
W. Taylor Kimberly,
Mónica Millán,
Milena Świtońska,
Ilaria Maestrini,
Régis Bordet,
Konark Malhotra,
Laura Mechtouff,
PN Sylaja
Publication year - 2021
Publication title -
cerebrovascular diseases
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.221
H-Index - 104
eISSN - 1421-9786
pISSN - 1015-9770
DOI - 10.1159/000518570
Subject(s) - medicine , meta analysis , modified rankin scale , odds ratio , cochrane library , systematic review , stroke (engine) , confidence interval , thrombolysis , diagnostic odds ratio , medline , ischemic stroke , ischemia , myocardial infarction , political science , law , engineering , mechanical engineering
Background: Hemorrhagic transformation (HT) is a complication that occurs spontaneously or after thrombolysis in acute ischemic stroke (AIS) and can increase morbidity and mortality. The association of biomarkers with the risk of HT has been variably reported. We conducted a systematic review of the literature and meta-analysis and sought to compare blood biomarkers associated with HT and its subtypes by evaluating its predictability and correlation with outcome in AIS. Methods: The study protocol was registered in the PROSPERO database (CRD42020201334) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Among 2,230 articles identified from Cochrane Library, PubMed, and Web of Science databases, 30 quality-appraised articles were found eligible. Meta-analysis was conducted for matrix metalloproteinase-9 (MMP-9), cellular fibronectin (c-Fn), ferritin, S100 calcium-binding protein B (S100B), and neutrophil-lymphocyte ratio (NLR). We also reviewed biomarkers for correlation with the functional outcome at 90 days from stroke onset (poor outcome modified Rankin scale >2). Results: The pooled diagnostic odds ratio (DOR pooled ) was the highest for baseline c-Fn levels (299.253 [95% CI, 20.508–4,366.709]), followed by MMP-9 (DOR pooled , 29.571 [95% CI 17.750–49.267]) and ferritin (DOR pooled , 24.032 [95% CI 2.557–225.871]). However, wide confidence intervals for ferritin and c-Fn suggested lesser reliability of the markers. Patients with MMP-9 levels ≥140 ng/mL were 29.5 times at higher risk of developing symptomatic HT after AIS (area under the curve = 0.881). S100B (DOR pooled , 6.286 [95% CI, 1.861–21.230]) and NLR (DOR pooled , 5.036 [95% CI, 2.898–8.749]) had lower diagnostic accuracies. Among the markers not included for meta-analysis, caveolin-1, thrombin-activated fibrinolysis inhibitor, plasminogen activator inhibitor-1, and soluble ST2 were highly sensitive. Elevated levels of MMP-9, ferritin, and NLR were found to be associated with poor functional outcomes and mortality. Conclusion: Of the 5 biomarkers, there was enough evidence that MMP-9 has higher diagnostic accuracy for predicting the risk of HT before thrombolysis. MMP-9, ferritin, and NLR also predicted poor short-term outcomes.