Upregulation of CD40 ligand and enhanced monocyte-platelet aggregate formation are associated with worse clinical outcome after ischaemic stroke

Summary

The white blood cell count and mean platelet volume determined shortly after the symptom onset are known as independent predictors for clinical outcome after stroke. In the present study we sought to evaluate the prognostic value of platelet-derived inflammatory biomarkers measured prospectively after an ischaemic event. Using five-colour flow cytometry, the platelet surface expression of CD40L, CD62P and subpopulations of leukocyte-platelet aggregates were assessed in 93 stroke patients on the first (V₀), 10^th (V₁) and 90^th (V₂) day after stroke, and once in 65 disease controls. The clinical outcome was evaluated using the Scandinavian Stroke Scale (SSS) and modified Rankin Scale (mRS) at the same time points as blood sampling and 24 months after the event. Patients with either CD40L surface expression or the percentage of monocyte-platelet aggregates (M-plt) in the third tertile (T3) at V₀ had a significantly lower score on the SSS at V₁. Patients with the percentage M-plt at V₀ higher than the median value of M-plt in controls were at increased risk of SSS < 40 at V₁ (odds ratio: 2.6; 95% confidence interval [CI]: 1.4 – 8.7; p=0.006). Patients with the percentage of M-plt in T3 at V₀ showed progressive decline in survival (hazard ratio [HR]: 1.6; 95% CI: 1.1–1.9; p=0.02) and a significantly higher number of recurrent vascular events (HR: 2.64; 95% CI: 1.3–3.2; p=0.02) when compared to the first tertile. In conclusion, increased levels of M-plt could be a predictive marker for both early outcome and long-term prognosis while increased CD40L was correlated with worse clinical outcome.

The preliminary results of this study were presented in part during a poster session at the 62^nd Annual Meeting of the American Academy of Neurology in Toronto, 7–17 April 2010.

Keywords

Leukocyte-platelet aggregates - CD40L - stroke - prognostic factors

• References

• 1 Kazmierski R, Guzik P, Ambrosius W. et al. Predictive value of white blood cell count on admission for in-hospital mortality in acute stroke patients.. Clin Neurol Neurosurg 2004; 107: 38-43.
• 2 Elkind MSV, Cheng J, Rundek T. et al. Leukocyte count predicts outcome after ischemic stroke: the Northern Manhattan Stroke Study.. J Stroke Cerebrovasc Dis 2004; 13: 220-227.
• 3 Grau AJ, Boddy AW, Dukovic DA. et al. for the CAPRIE Investigators. Leukocyte count as an independent predictor of recurrent ischemic events. Stroke 2004; 35: 1147-1152.
• 4 Bath P, Algert C, Chapman N. et al. PROGRESS Collaborative Group. Associations of mean platelet volume with risk of stroke among 3134 individuals with history of cerebrovascular disease. Stroke 2004; 35: 622-626.
• 5 Michelson AD, Barnard MR, Hechtman H. et al. In vivo tracking of platelets: circulating degranulated platelets rapidly lose surface P-selectin but continue to circulate and function. Proc Natl Acad Sci USA 1996; 93: 11877-11883.
• 6 Anand SX, Viles-Gonzalez JF, Badimon JJ. et al. Membrane-associated CD40L and sCD40L in atherothrombotic disease.. Thromb Haemost 2003; 90: 377-384.
• 7 Michelson AD, Barnard MR, Krueger LA. et al. Circulating monocyte-platelet aggregates are a more sensitive marker of in vivo platelet activation than platelet surface P-selectin: studies in baboons, human coronary intervention, and human acute myocardial infarction.. Circulation 2001; 104: 1533-1537.
• 8 Adams Jr HP, 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: 35-41.
• 9 Bamford J, Sandercock P, Dennis M. et al. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991; 337: 1521-1526.
• 10 Sacco RL.. Risk factors and outcomes for ischemic stroke. Neurology 1995; 45: S4-10.
• 11 Garlichs CD, Kozina S, Fateh-Moghadam S. et al. Upregulation of CD40-CD40 ligand (CD154) in patients with acute cerebral ischemia.. Stroke 2003; 34: 1412-1418.
• 12 McCabe DJH, Harrison P, Mackie IJ. et al. Platelet degranulation and monocyte-platelet complex formation are increased in the acute and convalescent phases after ischaemic stroke or transient ischaemic attack.. Br J Haematol 2004; 125: 777-787.
• 13 Glass CK, Witztum JL.. Atherosclerosis: the road ahead. Cell 2001; 104: 503-516.
• 14 Yilmaz G, Granger DN.. Leukocyte recruitment and ischemic brain injury. Neuromol Med 2010; 12: 193-204.
• 15 Barone FC, Hillegass LM, Tzimas MN. et al. Time-related changes in myeloperoxidase activity and leukotriene B4 receptor binding reflect leukocyte influx in cerebral focal stroke. Mol Chem Neuropathol 1995; 24: 13-30.
• 16 Weyrich AS, Elstad MR, McEver RP. et al. Activated platelets signal chemokine synthesis by human monocytes. J Clin Invest 1996; 97: 1525-1534.
• 17 Fitzgerald GA.. COX-2 and beyond: approaches to prostaglandin inhibition in human disease. Nat Rev Dug Discov 2003; 2: 879-890.
• 18 Galt SW, Lindemann S, Medd D. et al. Differential regulation of matrix metalloproteinase-9 by monocytes adherent to collagen and platelets.. Circ Res 2008; 102: 302-309.
• 19 Schonbeck U, Libby P.. CD40 signaling and plaque instability. Circ Res 2001; 89: 1092-1103.
• 20 von Hundelshausen P, Weber KS, Huo Y. et al. RANTES deposition by platelets triggers monocyte arrest on inflamed and atherosclerotic endothelium.. Circulation 2001; 103: 1772-1777.
• 21 Dixon DA, Tolley ND, Bemis-Standoli K. et al. Expression of COX-2 in platelet-monocyte interactions occurs via combinatorial regulation involving adhesion and cytokine signaling.. J Clin Invest 2006; 95: 2297-2303.
• 22 Welsh P, Lowe GD, Chalmers J. et al. Associations of proinflammatory cytokines with the risk of recurrent stroke.. Stroke 2008; 39: 2226-2230.
• 23 Ishikawa M, Cooper D, Russel J. et al. Molecular determinants of the prothrombogenic and inflammatory phenotype assumed by the postischemic cerebral microcirculation.. Stroke 2003; 34: 1777-1782.
• 24 Li G, Sanders JM, Bevard MH. et al. CD40 ligand promotes Mac-1 expression, leukocyte recruitment, and neointima formation after vascular injury. Am J Pathol 2008; 172: 1141-1152.
• 25 Garlichs CD, Johm S, Schmeisser Y. et al. Upregulation of CD40-CD40 ligand (CD154) in patients with moderate hypercholesterolemia. Circulation 2001; 104: 2395-2400.
• 26 Cipollone F, Ferri C, Desideri G. et al. Preprocedural level of soluble CD40L is predictive of enhanced inflammatory response and restenosis after coronary angioplasty. Circulation 2003; 108: 2776-2782.
• 27 Michelson AD, Barnard MR, Krueger LA. et al. Circulating monocyte-platelet aggregates are a more sensitive marker of in vivo platelet activation than platelet surface P-selectin: studies in baboons, human coronary intervention, and human acute myocardial infarction.. Circulation 2001; 104: 1533-1537.
• 28 Aslanyan S, Weir CJ, Diener HC. et al. GAIN International Steering Committee and Investigators. Pneumonia and urinary tract infection after acute ischemic stroke: a tertiary analysis of the GAIN International Trial. Eur J Neurol 2004; 11: 49-53.
• 29 Urra X, Cervera A, Obach V. et al. Monocytes are major players in the prognosis and risk of infection after acute stroke.. Stroke 2009; 40: 1262-1268.
• 30 Urra X, Villamor N, Amaro S. et al. Monocyte subtypes predict clinical course and prognosis in human stroke.. J Cerebr Blood Flow Metab 2009; 29: 994-1002.
• 31 Vargas M, Horcajada JP, Obach V. et al. Clinical consequences of infection in patients with acute stroke: is it prime time for further antibiotic trials?. Stroke 2006; 37: 461-465.