High-sensitive CRP in ischaemic stroke patients –  from risk factors to evolution


CRP stanovený vysoce senzitivní metodou u pa­cientů s ichemickou cévní mozkovou příhodou –  od rizikových faktorů po vývoj

Cíl: Bylo prokázáno, že C-reaktivní protein stanovený vysoce senzitivní metodou (high-sensitive C-reactive protein; hs-CRP) má dobrou senzitivitu při dia­gnostice cerebrovaskulárních příhod. Cílem studie bylo vyhodnotit spojitosti mezi hs-CRP a rizikovými faktory CMP, neurologickou poruchou, ischemií mozku a prognózou.

Materiál a metody: Studie zahrnula 153 pa­cientů rozdělených do dvou skupin: pa­cienti s akutní ischemickou CMP a pa­cienti s rizikovými faktory, kteří CMP neprodělali. V odebraných vzorcích krve byla stanovena hladina hs-CRP v séru. Neurologické postižení bylo hodnoceno při přijetí do nemocnice a při propuštění pomocí NIHSS (National Institute of Health Score Scale) škály. Ve stejné skupině pa­cientů bylo v průběhu prvních 24 h po rozvinutí CMP provedeno vyšetření CT a byly zaznamenány známky časných ischemických lézí. Případy CMP byly rozděleny do podskupin pomocí TOAST klasifikace.

Výsledky: Hladiny hs-CRP v séru pa­cientů s CMP byly významně vyšší v porovnání s pa­cienty, kteří CMP neměli. Nejvyšší podíl pa­cientů s hladinami hs-CRP > 3 mg/ l byl pozorován u pa­cientů s CMP nejasné etiologie. U hs-CRP byla ukázána významná dia­gnostická schopnost identifikovat CMP; optimálním kritériem byla hladina 4,29 mg/ l. Poměr šancí u hs-CRP pozitivních pa­cientů ukázal zvýšené riziko CMP a ischemických lézí. Hladina hs-CRP pozitivně korelovala s NIHSS a časem testování a negativně s vývojem CMP.

Závěr: Hs-CRP je spolehlivý marker, který může být nápomocen při dia­gnóze CMP, její etiologické klasifikaci, klinických projevech a prognóze. Naše výsledky přispívají k identifikaci charakteristik CMP v populaci Bulharska.

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Klíčová slova:

high-sensitive C-reactive protein – stroke biomarkers – acute ischaemic stroke


Authors: M. Peycheva 1;  T. Deneva 2;  Z. Zahariev 1
Authors‘ workplace: Department of Neurology, Medical, University Plovdiv, Bulgaria 1;  Department of Clinical Laboratory, Medical University Plovdiv, Bulgaria 2
Published in: Cesk Slov Neurol N 2019; 82(5): 549-555
Category: Original Paper
doi: 10.14735/amcsnn2019549

Overview

Aim: High-sensitive C-reactive protein (hs-CRP) has demonstrated good sensitivity in the dia­g­nosis of cerebrovascular events. The study aimed to explore the as­sociations between hs-CRP and stroke risk factors, neurological impairment, cerebral ischaemia and prognosis.

Materials and methods: The study involved 153 patients categorized into two groups: patients with acute ischaemic stroke and patients with risk factors who had not had a stroke. Blood samples were col­lected to analyze the serum level of hs-CRP. The National Institutes of Health Stroke Scale (NIHSS) was used to determine the neurological disability of the stroke patients upon hospital admis­sion and upon discharge. Cerebral CT was performed on the same group of patients dur­­ing the first 24 h after stroke onset and evidence of early ischaemic lesions was recorded. The stroke cases were divided into subgroups accord­­ing to the TOAST clas­sification.

Results: The serum levels of hs-CRP of the stroke patients were significantly higher than in the non-stroke patients. The highest percentage of patients with hs-CRP values > 3mg/ L was observed in cases with stroke of undetermined aetiology. Hs-CRP showed a significant dia­gnostic ability in identify­­ing stroke with an optimal criterion of 4.29 mg/ L. The odds ratios for hs-CRP positive patients indicated an increased risk of stroke and ischaemic lesions. Hs-CRP cor­related positively with NIHSS at the time of test­­ing and negatively with stroke evolution.

Conclusion: Hs-CRP is a reliable marker that can be helpful for stroke dia­gnosis, aetiological clas­sification, clinical manifestation and prognosis. Our results contribute to identify­­ing the characteristics of stroke among the Bulgarian population.

Keywords:

C-reaktivní protein stanovený vysoce senzitivní metodou – biomarkery cévní mozkové příhody – akutní ischemická cévní mozková příhoda

Introduction

Ischaemic stroke is a complex dis­ease in which modifiable and non-modifiable risk factors play an important role [1]. Inflam­matory mechanisms are also involved in the stroke pathogenesis [2]. High-sensitive C-reactive protein (hs-CRP) is an acute phase protein that has demonstrated good sensitivity for cardiovascular and cerebrovascular dis­eases [3,4]. Recent studies have described its positive cor­relations with the unstable atherosclerotic plaques of the internal carotid artery [5– 7].

In our research we examined the as­sociations between hs-CRP and stroke risk factors and established its con­nections with neurological impairment, cerebral ischaemia and stroke evolution. We also present data on the characteristics of ischaemic stroke in the Bulgarian population.

Materials and methods

An observational, cros­s-sectional study was conducted for 6 months (from November 2017 through May 2018) and it enrol­led consecutively 153 patients under medical observation in the Clinic of Neurology, UMHAT “St George” –  Plovdiv, Bulgaria. It was approved by the Local Ethical Com­mittee. The inclusion criteria included risk factors for ischaemic stroke, such as a history of hypertension, carotid atherosclerosis, diabetes mel­litus, atrial fibril­lation and cardiovascular dis­ease. The exclusion criteria were autoim­mune dis­eases, cancer and inflam­matory and im­mune dis­eases. The selection was made by means of medical history, physical examination and laboratory investigations. Two main groups were formed: patients with acute ischaemic stroke and patients with risk factors but without a history of ischaemic stroke.

The information about comorbidity in all patients was col­lected through medical history, physical examination, laboratory investigations, electrocardiogram monitor­­ing and extracranial carotid duplex ultrasound investigation.

Blood samples from all the patients were col­lected to analyze the serum level of hs-CRP. In the stroke subgroup, the time from the stroke onset to tak­­ing the blood sample was recorded. The serum levels of hs-CRP were determined im­munoturbimetrical­ly us­­ing an automated clinical-chemical analyzer OLIMPUS AU400 (Beckman Coulter, Brea, CA, USA). Cerebrovascular risk was defined as high as hs-CRP > 3.0 mg/ L, fol­low­­ing the reference values given in the Beckman Coulter system manuals and cur­rent literature [3,4].

The National Institutes of Health Stroke Scale (NIHSS) was used to determine the neurological disability of the stroke patients. The neurological deficit upon hospital admis­sion and upon discharge was compared in the analysis of stroke evolution.

Cerebral CT was performed on the same group of patients dur­­ing the first 24 h after the stroke onset. The evidence of early ischaemic lesions in the af­fected vascular ter­ritory was also examined.

A stroke specialist reviewed the data and clas­sified the strokes accord­­ing to the TOAST clas­sification: large artery atherosclerosis (macroangiopathy), cardioembolic, small ves­sel dis­ease (lacunar), stroke of other determined aetiology and stroke of undetermined aetiology [8].

The data were analyzed us­­ing SPSS (IBM, Armonk, NY, USA), Version 25 [9] and MedCalc Statistical Software (MedCalc, Ostend, Belgium), Version 18.11.3 [10]. The descriptive statistics for continuously measured variables include mean values ± SD; and the frequencies and percentages for nominal and dichotomous variables. The continuously measured variables were screened for violations of normality us­­ing the Kolmogorov-Smirnov test. To examine significant dif­ferences between the stroke and non-stroke patient groups, we performed independent sample t-tests, when normality was observed (Kolmogorov-Smirnov P > 0.05) and we used the Man­n-Whitney U Test when normality was not in place (Kolmogorov-Smirnov P < 0.05). Comparisons of nominal and dichotomous data were performed through cross tabulation, the Chi-square test and Fisher’s exact test. To explore the dia­g­­nostic ability of hs-CRP to cor­rectly clas­sify patients as stroke or non-stroke, we applied receiver operat­­ing characteristic (ROC) curve analysis and Youden’s index to identify the hs-CRP optimal criterion with the cor­respond­­ing sensitivity and specificity. The optimal criterion was used to recode hs-CRP into positive and negative cases and calculate the odds ratio (OR) with the incidence of stroke and ischaemic lesions evident on cerebral CT. For the stroke patients, we examined the con­nection between hs-CRP and the neurological deficit measured by NIHSS, the time of hs-CRP testing, and stroke evolution through cor­relation analysis. Person-r cor­relation was employed when both variables were measured continuously and normal­ly distributed, and Spearman-rho cor­relation in all other cases. The results were interpreted as statistical­ly significant if the P values were < 0.05.

Results

Demographic and clinical characteristics of the patients

The study involved 153 patients of a mean age of 65.08 ± 10.65 years, of whom 82 were males (53.6%). Seventy-nine patients had suf­fered an ischaemic stroke and 74 had not had an ischaemic stroke. The two groups did not dif­fer significantly in mean age (P = 0.386), gender distribution (P = 0.235), cases with carotid plaques (P = 0.439), cases with hypertension (P = 0.182) or cases with diabetes (P = 0.083). A significantly higher percentage of the patients with ischaemic stroke had nonvalvular atrial fibril­lation (P < 0.001) and cardiovascular dis­eases (P = 0.035) (ischaemic heart dis­ease, valvular heart dis­ease, heart failure and others). The demographic and clinical data are sum­marized in Tab. 1.

1. Demographic and clinical characteristics of the patients.
Demographic and clinical characteristics of the patients.
*statistically significant difference at P < 0.05; **statistically significant difference at P ≤ 0.01; a independent-samples t-test; b Fisher’s exact test
N – number; SD – standard deviation

Dia­gnostic ability of hs-CRP in ischaemic stroke

A significantly higher hs-CRP level (22.97 mg/ L ± 48.59) was observed in ischaemic stroke patients as compared to non-stroke patients (14.20 mg/ L ± 36.76). The percentage of patients with hs-CRP levels > 3 mg/ L was significantly higher in the stroke patients (71%) vs. 38% in the non-stroke patients; P < 0.001 (Tab. 2).

2. Hs-CRP levels in stroke and non-stroke patients
Hs-CRP levels in stroke and non-stroke patients
*statistically significant difference at P < 0.05; **statistically significant difference at P ≤ 0.01; a independent-samples t-test; b Fisher’s exact test
hs-CRP – high sensitivity C-reactive protein; N – number; SD – standard deviation

The distribution of hs-CRP values > 3mg/ L across the dif­ferent types of ischaemic stroke showed significant dif­ferences accord­­ing to the Chi-square test; P = 0.011 (Fig. 1). From the highest to the lowest, the percentage of patients with hs-CRP values > 3mg/ L were as fol­lows: 90% of the patients with stroke of undetermined aetiology (19/ 21); 79.35% of the patients with stroke caused by large artery atherosclerosis (23/ 25); 60% of those with lacunar stroke (9/ 15); 44.4% with cardioembolic stroke (4/ 5); and 33.3% of the patients with stroke of other determined aetiology (2/ 6).

Distribution of patients with hs-CRP levels > 3mg/L across stroke types.
*P = 0.011; P-value based on Chi-square test
hs-CRP – high-sensitive C-reactive protein<br>
Obr. 1. Distribuce pacientů s hladinami hs-CRP > 3 mg/l napříč typy cévní mozkové
příhody.
* p = 0,011; p-hodnota získána pomocí chí-kvadrát testu
hs-CRP – C-reaktivní protein stanovený vysoce senzitivní metodou
1. Distribution of patients with hs-CRP levels > 3mg/L across stroke types. *P = 0.011; P-value based on Chi-square test hs-CRP – high-sensitive C-reactive protein
Obr. 1. Distribuce pacientů s hladinami hs-CRP > 3 mg/l napříč typy cévní mozkové příhody. * p = 0,011; p-hodnota získána pomocí chí-kvadrát testu hs-CRP – C-reaktivní protein stanovený vysoce senzitivní metodou

The ROC curve results revealed a significant dia­gnostic ability of hs-CRP in dif­ferentiat­­ing stroke from non-stroke patients (area under curve [AUC] = 0.753; P < 0.001) (Tab. 3).

3. Receiver operating characteristic curve for hs-CRP and ischemic stroke.
Receiver operating characteristic curve for hs-CRP and ischemic stroke.
a – under the nonparametric assumption; b – null hypothesis: true area = 0.5; hs-CRP – high sensitivity C-reactive protein

Figure 2 shows the ROC curve between hs-CRP and ischaemic stroke. The universal­ly accepted criterion of hs-CRP > 3mg/ L, as­sociated with increased cardiovascular risk, showed a sensitivity of 70.89 and a speci­ficity of 63.51 in our sample. On the other hand, accord­­ing to Youden’s index, our data showed hs-CRP > 4.29 mg/ L as the optimal criterion with a sensitivity of 62.03 (95% CI 50.4– 72.7) and a specificity of 81.08 (95% CI 70.3– 89.3).

Receiver operating characteristic curve between hs-CRP and ischaemic stroke.
AUC – area under curve; hs-CRP – high-sensitive C-reactive protein<br>
Obr. 2. ROC křivka mezi hs-CRP a ischemickou CMP.
AUC – plocha pod křivkou; hs-CRP – C-reaktivní protein stanovený vysoce senzitivní
metodou
2. Receiver operating characteristic curve between hs-CRP and ischaemic stroke. AUC – area under curve; hs-CRP – high-sensitive C-reactive protein
Obr. 2. ROC křivka mezi hs-CRP a ischemickou CMP. AUC – plocha pod křivkou; hs-CRP – C-reaktivní protein stanovený vysoce senzitivní metodou

We recoded the hs-CRP variable from a continuous into a dichotomous scale (1 = hs-CRP positive; 0 = hs-CRP negative) us­­ing the hs-CRP optimal cut-off value of 4.29 mg/ L and calculated the ORs for the incidence of stroke and early ischaemic lesions observed on cerebral CT (Fig. 3). The results showed significant ORs in both cases. The OR for stroke incidence showed a 6.78 times increased risk of stroke as­sociated with hs--CRP levels above 4.29 mg/ L (OR = 6.78; 95% CI 3.27– 14.04; P < 0.001). The probability of early ischaemic changes seen on CT was 6.04 times higher in stroke patients with hs-CRP > 4.29 mg/ L (OR = 6.04; 95% CI 2.19– 16.62; P < 0.001).

Forest plot of the odds ratios for high-sensitive C-reactive protein positive cases
vs. the incidence of ischaemic stroke and ischaemic lesions seen on early cerebral CT.<br>
Obr. 3. Znázornění typu „forest plot“ poměru šancí pozitivních případů C-reaktivního proteinu
stanoveného vysoce senzitivní metodou vs. incidence ischemické CMP a ischemických
lézí časně zřetelných na CT.
3. Forest plot of the odds ratios for high-sensitive C-reactive protein positive cases vs. the incidence of ischaemic stroke and ischaemic lesions seen on early cerebral CT.
Obr. 3. Znázornění typu „forest plot“ poměru šancí pozitivních případů C-reaktivního proteinu stanoveného vysoce senzitivní metodou vs. incidence ischemické CMP a ischemických lézí časně zřetelných na CT.

Cor­relations between hs-CRP levels and other parameters

For the stroke patients, we examined the con­nection between hs-CRP and the neurological impairment measured by the NIHSS, the time of hs-CRP test­­ing mea­sured in hours after the stroke, and the stroke evolution. The results are sum­marized in Tab. 4 and il­lustrated in Fig. 4.

4. Correlation results for hs-CRP and other parameters
Correlation results for hs-CRP and other parameters
*statistically significant difference at P < 0.05; **statistically significant difference at P ≤ 0.01; r – Pearson r correlation; rs – Spearman rho correlation; hs-CRP – high sensitivity C-reactive protein; N – number; NIHSS – National Institute of Health Stroke Scale

Hs-CRP relationship with NIHSS, time of hs-CRP testing, and stroke evolution.
hs-CRP – high-sensitive C-reactive protein; NIHSS – National Institutes of Health Stroke Scale<br>
Obr. 4. Vztah hs-CRP a NIHSS, dobou stanovení hs-CRP a vývojem CMP.
Hs-CRP – C-reaktivní protein stanovený vysoce senzitivní metodou; NIHSS – National Institute of Health Stroke Scale
4. Hs-CRP relationship with NIHSS, time of hs-CRP testing, and stroke evolution. hs-CRP – high-sensitive C-reactive protein; NIHSS – National Institutes of Health Stroke Scale
Obr. 4. Vztah hs-CRP a NIHSS, dobou stanovení hs-CRP a vývojem CMP. Hs-CRP – C-reaktivní protein stanovený vysoce senzitivní metodou; NIHSS – National Institute of Health Stroke Scale

We observed a significant positive linear relationship between hs-CRP and the neurological deficit, measured with NIHSS upon hospital admis­sion (r = 0.322; P = 0.004). The time of the hs-CRP test also cor­related positively with the hs-CRP levels (r =0.229; P = 0.041). To il­lustrate the relationship, we plotted the mean hs-CRP values for four time periods: 24 h > 24– 72 h > 72– 120 h and > 120– 240 h, reveal­­ing the period of >120– 240 h as the peak of hs-CRP levels (53.31 mg/ L). When compar­­ing the neurological deficit upon hospital admis­sion and upon discharge we found a negative cor­relation between hs-CRP and stroke evolution (rs = – 0.344; P = 0.002). Lower hs--CRP levels were as­sociated with those patients whose condition had improved, whereas higher hs-CRP levels were observed in patients whose condition had worsened.

Discus­sion

The dia­gnosis of ischaemic stroke is based mainly on clinical evaluation and neuro-imag­­ing techniques [11,12]. The identification of ef­fective bio­markers for stroke dia­g­nosis and prognosis will help in develop­­ing proper bio­logical procedures and treatment options [13,14].

Some studies, includ­­ing the Framingham study, suggest that elevated plasma hs-CRP levels significantly predict the risk of future ischaemic stroke and transient ischaemic attack in the elderly [15,16]. Other studies have identified hs-CRP in patients with ischaemic stroke as a prognostic factor [17,18]. In order to investigate the importance of hs-CRP as a predictor or a short-term prognostic factor, we examined its con­nection with the stroke risk factors, neurological deficit, cerebral infarcts and evolution.

We analyzed the risk factors in two selected groups –  patients with acute ischaemic stroke and patients with risk factors but not suf­fer­­ing from ischaemic stroke. There were no significant dif­ferences accord­­ing to the non-modifiable risk factors such as, gender and age. Compar­­ing the comorbidity in both groups, we found that stroke patients are more af­fected by nonvalvular atrial fibril­lation and cardiovascular dis­eases. This result may indicate a trend for the Bulgarian population regard­­ing modifiable risk factors and it deserves further investigation.

The study also revealed that Bulgarian stroke patients have significantly higher serum levels of hs-CRP compared to the non-stroke patients. The percentage of patients with hs-CRP levels > 3 mg/ L was significantly higher in the stroke patients compared to the non-stroke patients. Studies of other populations have shown the same prevalence. Indian patients with acute ischaemic stroke had high hs-CRP (> 3 mg/ L) levels [19]. Di Napoli et al found hs-CRP levels (> 0.5 mg/ dL) in 95 Italian patients (74.2%) with acute ischaemic stroke upon admis­sion [20]. Muir et al have detected elevated Hs-CRP (> 10 mg/ L) levels in English stroke patients in the acute phase [21].

Based on the TOAST aetiology clas­sification system, cases of ischaemic stroke are divided into five categories (Fig. 1): stroke after large-artery atherosclerosis (LAA); stroke after cardiac embolism (CE); stroke after smal­l-artery occlusion (SAA); stroke of other determined aetiology (SOE); and stroke of undetermined aetiology (SUE) [8]. We found hs-CRP > 3 mg/ L in all stroke subtypes with maximum prevalence in the SUE (90%), fol­lowed by LAA (79.35%) and SAA (60%). Our results cor­respond with those of Chaudhuri et al [19], who found high hs--CRP levels in 72% of stroke patients with LAA. They are also similar to those of Huang et al [22], who established high hs-CRP levels in 63.9% of stroke patients with large artery atherosclerosis. On the other hand, our findings dif­fer from the results of Den Hertog et al [23] and Dewan et al [24], who reported a lower percentage of stroke patients with LAA and high levels of hs-CRP, 15% and 14.9%, resp. The increased level of hs-CRP observed in this stroke subtype is con­nected with the concept of increased hs-CRP in unstable and vulnerable carotid plaques [7,25].

In our study the highest percentage of patients with hs-CRP values > 3mg/ L was observed in patients with strokes of undetermined aetiology. This data can be explained due to the involvement of concur­rent mecha­nisms and comorbidity in the group of patients with SUE.

The lowest percentage (33.30%) of patients with hs-CRP values > 3mg/ L was found in the subgroup of patients with SOE. This result is similar to the percentage (40%) reported by Chaudhuri et al [19] and comparable to that of Rajeshwar et al [26].

The ROC curve analysis and Youden’s index provide confirmatory evidence about hs-CRP dia­gnostic ability in dif­ferentiat­­ing stroke from non-stroke patients. In our study with Bulgarian patients, we established an optimal criterion of 4.29 mg/ L.

We also examined some clinical aspects of our patients with ischaemic stroke. Analyz­­ing the data about hs-CRP and the ischaemic lesions observed on cerebral CT, we found that patients with high levels of hs-CRP were as­sociated with earlier evidence of ischaemic changes in the af­fected vascular ter­ritory. The ORs for hs-CRP positive patients indicated an increased risk of stroke and early ischaemic cerebral lesions for patients with hs-CRP levels > 4.29 mg/ L. This find­­ing cor­responds with previous analyses of patients with ischaemic and haemor­rhagic stroke, which have shown that ischaemic lesions are as­sociated with higher serum values of hs-CRP [27,28].

In our study, hs-CRP cor­related positively with the neurological as­ses­sment made by NIHSS, positively with the time of hs-CRP test­­ing and negatively with stroke evolution. These findings support other investigations which have observed that the hs-CRP level can predict the severity of ischaemic stroke, the ocur­rence of a new cerebrovascular accident and an unfavourable stroke outcome [29,30]. Indicula et al found that increased levels of hs-CRP were as­sociated with stroke severity and mortality rate [31]. The authors suggest that measur­­ing hs-CRP upon entry and upon discharge and 1– 3 months later may be useful, as patients with persistently elevated levels of hs-CRP are at a higher risk of future events.

The time of blood test­­ing and its ef­fect on hs-CRP levels has also been studied. Yeh et al examined the hs-CRP levels dur­­ing the acute and convalescent phases of 160 stroke patients [32]. They found that hs-CRP levels dur­­ing both phases were significantly and independently predictive of 90-day major adverse neurological events, defined as recur­rent stroke, neurological deficit with NIHSS ≥ 8, or death. In our study we revealed the period of > 120– 240 h as the peak of hs--CRP levels (53.31 mg/ L) but the cor­relation with stroke evolution measur­­ing neurological deficit at admis­sion and discharge was negative. Lower hs-CRP levels were as­sociated with those patients whose condition had improved. This result determinеs the role of hs-CRP as a short-term prognostic factor, regard­­ing its con­nection with the presence of ischaemic zone and with stroke severity and early outcome.

Conclusion

High-sensitive CRP plays an important role in the definition of stroke risk factors and aetiology, proper dia­gnosis, clinical manifestation and prognosis. Our results contribute to identify­­ing the characteristics of stroke among the Bulgarian population.

The authors declare they have no potential of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manu­script met the ICMJE “uniform requirements” for biomedical papers.

Marieta Peycheva, MD

Department of Neurology

Medical University Plovdiv

66 Peshtersko shosse bul.

4002 Plovdiv

Bulgaria

e-mail: mpeitcheva@yahoo.com

Accepted for review: 25. 5. 2019

Accepted for print: 21. 8. 2019


Sources

1. Boehme AK, Esenwa CE, Elkind M. Stroke risk factors, genetics, and prevention. Circ Res 2017; 120(3): 472– 495. doi: 10.1161/ CIRCRESAHA.116.308398.

2. Anrather J, Iadecola C. Inflam­mation and stroke: an overview. Neurotherapeutics 2016; 13(4): 661– 670. doi: 10.1007/ s13311-016-0483-x.

3. Ridker PM, Glynn RJ, Hen­nekens CH. C-reactive protein adds to the predictive value of total and HDL cholesterol in determin­­ing risk of first myocardial infarction. Circulation 1998; 97(20): 2007– 2011. doi: 10.1161/ 01.cir.97.20.2007.

4. Wakugawa Y, Kiyohara Y, Tanizaki Y et al. C-reactive protein and risk of first-ever ischemic and hemor­rhagic stroke in a general Japanese population: the Hisayama Study. Stroke 2006; 37(1): 27– 32. doi: 10.1161/ 01.STR.0000194958.88216.87.

5. Am­mirati E, Moroni F, Norata G. Markers of inflam­mation as­sociated with plaque progres­sion and instability in patients with carotid atherosclerosis. Mediators Inflamm 2015; 2015: 718329. doi: 10.1155/ 2015/ 718329.

6. Puz P, Lasek-Bal A, Ziaja D et al. Inflam­matory markers in patients with internal carotid artery stenosis. Arch Med Sci 2013; 9(2): 254– 260. doi: 10.5114/ aoms.2013.34533.

7. Deb­­ing E, Peeters E, Demanet C et al. Markers of inflam­mation in patients with symp­tomatic and asymp­tomatic carotid artery stenosis: a case-control study. Vasc Endovascular Surg 2008; 42(2): 122– 127. doi: 10.1177/ 1538574407307406.

8. Adams HP Jr, Bendixen BH, Kappel­le LJ et al. Clas­sification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24(1): 35– 41. doi: 10.1161/ 01.str.24.1.35.

9. IBM SPSS Statistics for Windows, Version 25.0. [online]. Available from URL: https:/ / www.ibm.com/ cz-en/ analytics/ sps­s-statistics-software.

10. MedCalc Statistical Software version 18.11.3. [online]. Available from URL: https: / / www.medcalc.org.

11. Yu H, Huang Y, Chen X et al. High-sensitivity C-reactive protein in stroke patients –  The importance in consideration of influence of multiple factors in the predictability for dis­ease severity and death. J Clin Neurosci 2017; 36: 12– 19. doi: 10.1016/ j.jocn.2016.10.020.

12. Tan JR, Tan KS, Koo YX et al­. Blood microRNAs in low or no risk ischemic stroke patients. Int J Mol Sci 2013; 14(1): 2072– 2084. doi: 10.3390/ ijms14012072.

13. Jia L, Hao F, Wang W et al. Circulat­­ing miR-145 is as­sociated with plasma high-sensitivity C-reactive protein in acute ischemic stroke patients. Cell Biochem Funct 2015; 33(5): 314– 319. doi: 10.1002/ cbf.3116.

14. Kitagawa K, Hosomi N, Nagai Y et al. Reduction in high-sensitivity C-reactive protein levels in patients with ischemic stroke by statin treatment: Hs-CRP Sub-Study in J-STARS. J Atheroscler Thromb 2017; 24(10): 1039– 1047. doi: 10.5551/ jat.39354.

15. Rost N, Wolf P, Kase C. Plasma concentration of C-reactive protein and risk of ischemic stroke and transient ischemic attack: the Framingham Study. Stroke 2001; 32(11): 2575– 2579. doi: 10.1161/ hs1101.098151.

16. Di Napoli M, Schwaninger M, Cappel­li R et al. Evaluation of C-reactive protein measurement for as­ses­s­­ing the risk and prognosis in ischemic stroke: a statement for health care profes­sionals from the CRP Pool­­ing Project members. Stroke 2005; 36(6): 1316– 1329. doi: 10.1161/ 01.STR.0000165929.78756.ed.

17. Winbeck K, Poppert H, Etgen T et al. Prognostic relevance of early serial C-Reactive rotein mea­surements after first ischaemic stroke. Stroke 2002; 33(10): 2459– 2464. doi: 10.1161/ 01.str.0000029828.51413.82.

18. Di Napoli M, Elkind SV, Wagner AP. Role of C-reactive protein in cerebrovascular stroke. Expert Rev Cardiovasc Ther 2011; 9(12): 1565– 1584. doi: 10.1586/ erc.11.159.

19. Chaudhuri JR, Mridula KR, Umamahesh M et al. High sensitivity C-reactive protein levels in acute ischemic stroke and subtypes: a study from a tertiary care center. Iran J Neurol 2013; 12(3): 92– 97.

20. Di Napoli M, Papa F, Bocola V. C-reactive protein in ischemic stroke: an independent prognostic factor. Stroke 2001; 32(4): 917– 924. doi: 10.1161/ 01.str.32.4.917.

21. Muir KW, Weir CJ, Alwan W et al. C-reactive protein and outcome after ischemic stroke. Stroke 1999; 30(5): 981– 985. doi: 10.1161/ 01.str.30.5.981.

22. Huang Y, J­­ing J, Zhao XQ et al. High-sensitivity C-reactive protein is a strong risk factor for death after acute ischemic stroke among Chinese. CNS Neurosci Ther 2012; 18(3): 261– 266. doi: 10.1111/ j.1755-5949.2012.00296.x.

23. den Hertog HM, van Ros­sum JA, van der WorpHB et al. C-reactive protein in the very early phase of acute ischemic stroke: as­sociation with poor outcome and death. J Neurol 2009; 256(12): 2003– 2008. doi: 10.1007/ s00415-009-5228-x.

24. Dewan KR, Rana PV. C-reactive protein and early mortality in acute ischemic stroke. Kathmandu Univ Med J (KUMJ) 2011; 9(36): 252– 255.

25. Garcia BA, Ruiz C, Chacon P et al. High-sensitivity C-reactive protein in high-grade carotid stenosis: risk marker for unstable carotid plaque. J Vasc Surg 2003; 38(5): 1018– 1024. doi: 10.1016/ S0741.

26. Rajeshwar K, Kaul S, Al-Hazzani A et al. C-reactive protein and nitric oxide levels in ischemic stroke and its subtypes: cor­relation with clinical outcome. Inflam­mation 2012; 35(3): 978– 984. doi: 10.1007/ s10753-011-9401-x.

27. Lal R, Gupta A, Virmani SK et al. High sensitivity C-reactive protein as a prognostic marker in ischaemic and haemor­rhagic stroke. Int J Adv Med 2016; 3(2): 372– 377. doi: 10.18203/ 2349-3933.ijam20161094.

28. Roudbary SA, Saadat F, Forghanparast K et al. Serum C-reactive protein level as a bio­marker for dif­ferentiation of ischemic from haemor­rhagic stroke. Acta Med Iran 2011; 49(3): 149– 152.

29. Gong X, Zou X, Liu L et al. Prognostic value of inflam­matory mediators in 1-year outcome of acute ischemic stroke with middle cerebral artery stenosis. Mediat Inflamm 2013; 2013: 850714. doi: 10.1155/ 2013/ 850714.

30. Luo Y, Wang Z, Li J et al. Serum CRP concentrations and severity of ischemic stroke subtypes. Can J Neurol Sci 2012; 39(1): 69– 73.

31. Idicula TT, Brogger J, Naess H et al. Admis­sion C-reactive protein after acute ischaemic stroke is as­sociated with stroke severity and mortality: the Bergen stroke study. BMC Neurology 2009; 9: 18. doi: 10.1186/ 1471-2377-9-18.

32. Yeh KH, Tsai TH, Chai HT et al. Comparison of acute versus convalescent stage high-sensitivity C-reactive protein level in predict­­ing clinical outcome after acute ischemic stroke and impact of erythropoietin. J Transl Med 2012; 10: 6. doi: 10.1186/ 1479-5876-10-6.

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Paediatric neurology Neurosurgery Neurology

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