New diagnostic and prognostic biomarkers of the ischemic brain damage

Background. To determine the optimal approach to managing patients in the acute period of stroke, the search for biomarkers that can increase value of existing diagnostic methods continues. Objective: to clarify the significance of the levels of neuron-specific enolase (NSE), glial fibrillar acid protein (GFAP), NR2-antibodies in the blood serum (BS) of patients in the acute period of ischemic stroke (IS) in dynamics, determine their relationship with the severity of neurological disturbances and short-term outcome. Design and methods. 40 patients were examined in the acute period of IS, mean age 72.6 ± 1.9 years. The levels of biomarkers were determined in the BS in the first 72 hours of IS and on days 10–14. Results. The concentration of NSE and GFAP in patients with IS in the first 72 hours exceeded the reference values and significantly decreased by 10–14 days (34.9 ± 5.9 → 17.7 ± 1.1; p = 0.007 and 0.4 ± 0, 1 → 0.2 ± 0.005, p = 0.22 respectively). The level of NR2 antibodies did not exceed of the reference values (1.01 ± 0.3), and in dynamics, by 10–14 days, an increase in the indicator was noted (1.1 ± 0.3), p = 0.007. In patients with more severe symptoms, the concentration of NSE, GFAP and NR2 antibodies was higher by 10–14 days. Patients who had an unfavorable short-term outcome by 10–14 days had a higher level of NSE, GFKB and NR2 antibodies. Conclusion. The investigated substances can be used as biomarkers in IS to control the degree of damage to the brain tissue, monitor the worsening of the pathological process, as well as for prognostic purposes.

stroke, stroke biomarker, neuron-specific enolase, glial fibrillary acidic protein, NR2-antibodies, N-methyl-D-aspartate receptors, short-term outcome, prognosis

1. Feigin VL, Norrving B, George MG, et al. Prevention of stroke: a strategic global imperative. Nat Rev Neurol. 2016; 12 (9): 501–512.

2. Castellanos M, Serena J. Applicability of biomarkers in ischemic stroke. Cerebrovasc Dis. 2007; 24 Suppl 1: 7–15.

3. Maas MB, Furie KL. Molecular biomarkers in stroke diagnosis and prognosis. Biomark Med. 2009; 3 (4): 363–383.

4. Saengen AK, Christenson RH. Stroke biomarkers: progress and challenges for diagnosis, prognosis, differentiation and treatment. Clin Chem. 2010; 56 (1): 21–33.

5. Biomarkers Definitions Working Group. Biomarkers and surrogate endpoints: preferred definitions and conceptual framework. Clin Pharmacol Ther. 2001; 69(3): 89–95.

6. Whiteley W, Tseng M-C, Sandercock P. Blood biomarkers in the diagnosis of ischemic stroke: a systematic review. Stroke. 2008; 39(10): 2902–2909.

7. Topuzova MP, Alekseeva TM, Panina EB, et al. The possibility of using neuron-specific enolase as a biomarker in the acute period of stroke. Zhurnal nevrologii i psihiatrii im. S. S. Korsakova=S.S. Korsakov journal of neurology and psychiatry. 2019; 119(8-2): 53–62. In Russian

8. Topuzova MP, Alekseeva TM, Panina EB, et al. The possibility of using glial fibrillary acidic protein as a biomarker in the acute period of stroke. Rossijskij nevrologicheskij zhurnal=Russian neurological journal. 2019; 24 (4): 4–15. In Russian

9. Topuzova MP, Alekseeva TM, Panina EB, et al. NR2 antibodies as diagnostic and prognostic stroke biomarker. Arterial’naya gipertenziya=Arterial hypertension. 2020; 26 (1): 27–36. In Russian

10. Missler U, Wiesmann M, Friedrich C, et al. S-100 protein and neuron-specific enolase concentrations in blood as indicators of infarction volume and prognosis in acute ischemic stroke. Stroke. 1997; 28(10): 1956–1960.

11. Laskowitz DT, Grocott H, Hsia A, et al. Serum markers of cerebral ischemia. J Stroke Cerebrovasc Dis. 1998; 7 (4): 234–241.

12. Eng LF. Glial fibrillary acidic protein (GFAP) the major protein of glial intermediate filaments in differentiated astrocytes. J Neuroimmunol. 1985; 8 (4-6): 203–214.

13. Missler U, Wiesmann M, Wittmann G, et al. Measurement of glial fibrillary acidic protein in human blood: analytical method and preliminary clinical results. Clin Chem. 1999; 45 (1): 138–141.

14. Lundgaard I, Osório MJ, Kress BT, et al. White matter astrocytes in health and disease. Neuroscience. 2014; 276: 161–173.

15. Kogure T, Kogure K. Molecular and biochemical events within the brain subjected to cerebral ischemia (targets for therapeutical intervention). Clin Neurosci. 1997; 4 (4): 179–183.

16. Shimada N, Graf R, Rosner G, et al. Ischemic flow threshold for extracellular glutamate increase in cat cortex. J Cereb Blood Flow Metab. 1989; 9 (5): 603–606.

17. Jones TH, Morawetz RB, Crowell RM, et al. Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg. 1981; 54 (6): 773–782.

18. Choi DW, Maulucci-Gedde M, Kriegstein AR. Glutamate neurotoxicity in cortical cell culture. J Neurosci. 1987; 7 (2): 357–368.

19. Benveniste H, Drejer J, Schousboe A, et al. Elevation of the extracellular concentrations of glutamate and aspartate in rat hippocampus during transient cerebral ischemia monitored by intracerebral microdialysis. J Neurochem. 1984; 43 (5): 1369–1374.

20. Meldrum B, Evans M, Griffiths T, et al. Ischaemic brain damage: the role of excitatory activity and of calcium entry. Br J Anaesth. 1985; 57 (1): 44–46.

21. Choi DW, Rothman SM. The role of glutamate neurotoxicity in hypoxic-ischemic neuronal death. Annu Rev Neurosci. 1990; 13: 171–182.

22. Okubo Y, Sekiya H, Namiki S, et al. Imaging extrasynaptic glutamate dynamics in the brain. Proc Natl Acad Sci USA. 2010; 107 (14): 6526–6531.

23. Wang Y, Qin Z-H. Molecular and cellular mechanisms of excitotoxic neuronal death. Apoptosis. 2010; 15 (11): 1382–1402.

24. Li F, Tsien JZ. Memory and the NMDA receptors. N Engl J Med. 2009; 361 (3): 302–303.

25. Levite M. Glutamate receptor antibodies in neurological diseases: anti-AMPA-GluR3 antibodies, antiNMDA-NR1 antibodies, anti-NMDA-NR2A/B antibodies, anti-mGluR1 antibodies or anti-mGluR5 antibodies are present in subpopulations of patients with either: epilepsy, encephalitis, cerebellar ataxia, systemic lupus erythematosus (SLE) and neuropsychiatric SLE, Sjogren’s syndrome, schizophrenia, mania or stroke. These autoimmune antiglutamate receptor antibodies can bind neurons in few brain regions, activate glutamate receptors, decrease glutamate receptor’s expression, impair glutamate-induced signaling and function, activate blood brain barrier endothelial cells, kill neurons, damage the brain, induce behavioral/ psychiatric/cognitive abnormalities and ataxia in animal models, and can be removed or silenced in some patients by immunotherapy. J Neural Transm (Vienna). 2014; 121 (8): 1029–1075.

26. Gappoeva MU, Izykenova GA, Granstrem OK, et al. Expression of NMDA neuroreceptors in experimental ischemia. Biochemistry (Mosc). 2003; 68 (6): 696–702.

27. Gingrich MB, Traynelis SF. Serine proteases and brain damage – is there a link? Trends Neurosci. 2000; 23 (9): 399–407.

28. Dambinova SA, Khounteev GA, Skoromets AA. Multiple panel of biomarkers for TIA/stroke evaluation. Stroke. 2002; 33 (5): 1181–1182.

29. Dambinova SA, Skoromets AA, Skoromets AP. Biomarkers of cerebral ischemia. Development, research and practice. SPb.: “IPK Costa LLC”, 2013. 336 p. In Russian

30. Klimenko LL, Skalny AV, Turna AA, et al. Serum trace element profiles, prolactin, and cortisol in transient ischemic attack patients. Biol Trace Elem Res. 2016; 172 (1): 93–100.

31. Nayak AR, Badar SR, Lande N, et al. Prediction of outcome in diabetic acute ischemic stroke patients: a hospital-based pilot study report. Ann Neurosci. 2016; 23 (4): 199–208.

32. Kamchatnov PR, Chugunov AV, Ruleva NYu, et al. Autoantibodies to GFAP (glial fibrillary acidic protein) and to dopamine in patients with acute and chronic cerebrovascular disоrders. Health. 2010; 2 (12):1366–1371.

33. Ren C, Kobeissy F, Alawieh A, et al. Assessment of Serum UCH-L1 and GFAP in acute stroke patients. Sci Rep. 2016; 6: 24588.

34. Weissman JD, Khunteev GA, Heath R, et al. NR2 antibodies: risk assessment of transient ischemic attack (TIA)/ stroke in patients with history of isolated and multiple cerebrovascular events. J Neurol Sci. 2011; 300 (1-2): 97–102.

35. Dambinova SA, Aliev KT, Bondarenko EV, et al. The biomarkers of cerebral ischemia as a new method for the validation of the efficacy of cytoprotective therapy. Zhurnal nevrologii i psihiatrii im. S. S. Korsakova=S.S. Korsakov Journal of Neurology and Psychiatry. 2017; 117 (5): 62–67. In Russian

36. Undén J, Strandberg K, Malm J, et al. Explorative investigation of biomarkers of brain damage and coagulation system activation in clinical stroke differentiation. J Neurol. 2009; 256 (1): 72–77.

37. Gusev EI, Skvortsova VI, Izykenova GA, et al. The level of autoantibodies to glutamate receptors in the blood serum of patients in the acute period of ischemic stroke. Zhurnal nevrologii i psihiatrii im. S.S. Korsakova = S.S. Korsakov Journal of Neurology and Psychiatry. 1996; 96 (5): 68–72. In Russian

38. Dambinova SA, Khounteev GA, Izykenova GA, et al. Blood test detecting autoantibodies to N-methyl-Daspartate neuroreceptors for evaluation of patients with transient ischemic attack and stroke. Clin Chem. 2003; 49 (10): 1752–1762.

39. Sienkiewicz-Jarosz H, Gałecka-Wolska M, Bidziński A, et al. Predictive value of selected biochemical markers of brain damage for functional outcome in ischaemic stroke patients. Neurol Neurochir Pol. 2009; 43 (2): 126–133.

40. Liu G, Geng J. Glial fibrillary acidic protein as a prognostic marker of acute ischemic stroke. Hum Exp Toxicol. 2018; 37 (10): 1048–1053.