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Cardioembolic Ischemic Stroke Gene Expression Fingerprint in Blood: a Systematic Review and Verification Analysis

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Abstract

An accurate etiological classification is key to optimize secondary prevention after ischemic stroke, but the cause remains undetermined in one third of patients. Several studies pointed out the usefulness of circulating gene expression markers to discriminate cardioembolic (CE) strokes, mainly due to atrial fibrillation (AF), while only exploring them in small cohorts. A systematic review of studies analyzing high-throughput gene expression in blood samples to discriminate CE strokes was performed. Significantly dysregulated genes were considered as candidates, and a selection of them was validated by RT-qPCR in 100 patients with defined CE or atherothrombotic (LAA) stroke etiology. Longitudinal performance was evaluated in 12 patients at three time points. Their usefulness as biomarkers for AF was tested in 120 cryptogenic strokes and 100 individuals at high-risk for stroke. Three published studies plus three unpublished datasets were considered for candidate selection. Sixty-seven genes were found dysregulated in CE strokes. CREM, PELI1, and ZAK were verified to be up-regulated in CE vs LAA (p = 0.010, p = 0.003, p < 0.001, respectively), without changes in their expression within the first 24 h after stroke onset. The combined up-regulation of these three biomarkers increased the probability of suffering from CE stroke by 23-fold. In cryptogenic strokes with subsequent AF detection, PELI1 and CREM showed overexpression (p = 0.017, p = 0.059, respectively), whereas in high-risk asymptomatic populations, all three genes showed potential to detect AF (p = 0.007, p = 0.007, p = 0.015). The proved discriminatory capacity of these gene expression markers to detect cardioembolism even in cryptogenic strokes and asymptomatic high-risk populations might bring up their use as biomarkers.

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Funding

Neurovascular Research Laboratory acknowledges funding for this project by PI15/00354 and PI18/804 grant from Fondo de Investigaciones Sanitarias and takes part in the Spanish stroke research network INVICTUS+ (RD16/0019/0021) of the Instituto de Salud Carlos III (co-financed by the European Regional Development Fund, FEDER). Moreover, it has been partially financed by 201528-30-31-3 grant from Fundació la Marató de TV3.

A.B is supported by a Juan Rodés research contract JR16/00008 from the Instituto de Salud Carlos III.

Some parts of this work were done in collaborative agreement through the International Biomarker in Cerebrovascular Diseases (IBCD) study group.

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Author notes

  1. Teresa García-Berrocoso and Elena Palà contributed equally to this work.

Authors and Affiliations

  1. Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR), Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Pg. Vall d’Hebron 119-129, 08035, Barcelona, Spain

    Teresa García-Berrocoso, Elena Palà, Marta Consegal, Alex Negro, Natalia Gill, Anna Penalba, Hector Huerga Encabo, Israel Fernández-Cadenas, Alejandro Bustamante & Joan Montaner

  2. Neuroscience Section, Department of Neurofarba, University of Florence, Florence, Italy

    Benedetta Piccardi

  3. The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK

    Hector Huerga Encabo

  4. Department of Neurology and Center for Stroke Research Berlin, Charité University Hospital Berlin, Berlin, Germany

    Andreas Meisel & Christian Meisel

  5. Lawrence J. Ellison Ambulatory Care Center, Department of Neurology, University of California at Davis Medical Center, Sacramento, USA

    Glen C. Jickling

  6. Institut d’Investigació en Atenció Primària IDIAP Jordi Gol, Unitat de Suport a la Recerca de Barcelona, Barcelona, Spain

    Miguel Ángel Muñoz & Josep Lluis Clúa-Espuny

  7. Department of Cardiology, Hospital Universitario Virgen del Rocio, Seville, Spain

    Alonso Pedrote

  8. Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain

    Jorge Pagola & Jesús Juega

  9. Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville & Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain

    Joan Montaner

Authors
  1. Teresa García-Berrocoso
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  2. Elena Palà
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Contributions

T.G-B helped in the experimental design. B.P and T.G-B performed the articles searching and screening and, together with M.C, extracted data from selected articles. A.P, A.N, N.G, M.C, and H.H performed the experimental work. T.G-B, I.F-C, A.M, C.M, and GC.J generated original microarrays data. A.B, MA.M, JL.C-E, A.P, J.P, J.J, and J.M recruited patients and selected samples included in the verification assays. T.G-B and E.P performed statistical and bioinformatics analyses and contributed to the interpretation of results. J.M planned the whole project. T.G-B and E.P drafted the manuscript. All authors have critically reviewed the manuscript and approved the final article version.

Corresponding author

Correspondence to Joan Montaner.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (PR(AG)80/2012, PR(AG)154/2004, PR(AG)49/2014, and PR(AG)133/2015, respectively) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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García-Berrocoso, T., Palà, E., Consegal, M. et al. Cardioembolic Ischemic Stroke Gene Expression Fingerprint in Blood: a Systematic Review and Verification Analysis. Transl. Stroke Res. 11, 326–336 (2020). https://doi.org/10.1007/s12975-019-00730-x

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