Skip to main content
Download PDF

Non-survivor patients with malignant middle cerebral artery infarction showed persistently high serum malondialdehyde levels

BMC Neurology volume 19, Article number: 238 (2019) Cite this article

Abstract

Objective

Previously there have been found higher circulating malondialdehyde levels during the first week of ischemic stroke in patients with worst neurological functional outcome, and at moment of ischemic stroke in non-survivor patients. Thus, the aim of our study was to determine the potential role of serum malondialdehyde levels during the first week of a severe cerebral infarction to mortality prediction.

Methods

This study was observational, prospective, and multicenter. We included patients with a severe malignant middle cerebral artery infarction (MMCAI) defined as patients with computed tomography showing acute infarction in more than of 50% of the territory and Glasgow Coma Scale (GCS) lower than 9. We determined serum concentrations of malondialdehyde on days 1, 4 and 8 of MMCAI.

Results

Serum malondialdehyde concentrations at days 1 (p < 0.001), 4 (p < 0.001), and 8 (p = 0.001) of MMCAI in non-survivor patients (n = 34) were higher than in survivor patients (n = 34). ROC curve analyses showed that serum malondialdehyde concentrations at days 1, 4, and 8 of MMCAI had an AUC (95% CI) to predict 30-day mortality of 0.77 (0.65–0.86; p < 0.001), 0.82 (0.69–0.91; p < 0.001) and 0.84 (0.70–0.93; p < 0.001) respectively.

Conclusions

The new findings of our study were that serum malondialdehyde levels during the first week of MMCAI could be used as biomarkers to mortality prediction.

Peer Review reports

Introduction

A large quantity of disabilities, deaths and resources consumption are generated by ischemic stroke [1]. In ischemic stroke, in addition to cell death produced by brain vasculature obstruction that causes a reduction of blood containing oxygen and substrates to neurons, could appears a secondary brain injury mediated by oxidative stress [2,3,4,5,6]. Different end-products could appear during lipid peroxidation such as malondialdehyde, which is formed during cellular membrane phospholipids degradation [3, 4]. Afterwards malondialdehyde could be released to extracellular space and appears in the blood; and circulating malondialdehyde levels have been used as lipid oxidation biomarker [7, 8].

Previously have been found higher circulating malondialdehyde levels during the first week of ischemic stroke in patients with worst neurological functional outcome [9,10,11,12], and at moment of ischemic stroke in non-survivor patients [13, 14]. Thus, the aim of our study was to determine the potential role of serum malondialdehyde levels during the first week of a severe cerebral infarction to mortality prediction.

Methods

Design and subjects

This study was observational and prospective. This multicentre study was performed with the Institutional Review Board approval of the six participating hospitals and with the written informed consent of patient legal guardians. This study was carried out in the Intensive Care Units of the following hospitals: H. General de La Palma from Breña Alta, H. Universitario Dr. Negrín from Las Palmas de Gran Canaria, H. Insular from Las Palmas de Gran Canaria, H. Universitario Nuestra Señora de Candelaria from Santa Cruz de Tenerife, H. Clínico Universitario de Valencia from Valencia, and H. Universitario de Canarias from La Laguna.

We included patients with a severe malignant middle cerebral artery infarction (MMCAI), defined as computed tomography showing acute infarction in more than of 50% of the territory and Glasgow Coma Scale (GCS) [15] lower than 9; and there were excluded patients with brain hemorrhage, less than 18 years of age, inflammatory or malignant disease, or pregnancy.

Previously, our team determined serum malondialdehyde concentrations in some of those patients in the day of a severe MMCAI [14]. In this current work, we determine serum malondialdehyde concentrations at days 1, and also at days 4 and 8.

Clinical and demographic variables

We recorded the following variables from the patients: age, arterial hypertension, sex, chronic obstructive pulmonary disease (COPD), diabetes mellitus, heart failure, chronic renal failure, temperature, CGS, lactic acid, sodium, bilirubin, creatinine, glycaemia, pressure of arterial oxygen (PaO2), fraction inspired oxygen (FI02), PaO2/FIO2 ratio, platelets, leukocytes, haemoglobin, fibrinogen, international normalized ratio (INR), activated partial thromboplastin time (aPTT), Acute Physiology and Chronic Health Evaluation II (APACHE II) score [16], thrombolysis, volumen infarction, haemorrhagic transformation, midline shift, and descompresive craniectomy. Thirty-day mortality was considered as the end-point study.

Meassure of serum malondialdehyde concentrations

We obtained serum blood samples on days 1, 4 and 8 of MMCAI and were frozen at − 80 °C until the determination of serum malondialdehyde concentrations. All assays for the meassure of malondialdehyde concentrations were carried out in the Physiology Department of Medicine Faculty of La Laguna University (Tenerife, Spain). The meassure of malondialdehyde concentrations was performed according to thiobarbituric acid-reactive substance (TBARS) method by Kikugawa et al. [17]. We mixed serum (200 μL), thiobarbituric acid (2.5 mL at 0.8%), sodium dodecyl sulfate (200 μL at 8.1%), trichloroacetic acid (1.5 mL with pH 3.5) and butylated hydroxytoluene (50 μL at 0.8%). We kept the mixture during 1 h at 5 °C and later it was heated during 1 h at 100 °C. Afterwards, n-butanol was extracted. Finally, the sample was placed doubly in a 96-well plate and read at 535 nm with a spectrophotometer reader (Benchmark Plus, Bio-Rad, Hercules, CA, USA). The assay detection limit, intra-assay coefficient variation, and inter-assay coefficient variation were of 0.08 nmol/ml, 1.82, and 4.01% respectively.

Statistical methods

Medians (and interquartile ranges) were used to describe continuous variables, and frequencies (and percentages) to describe categorical variables. Wilcoxon-Mann-Whitney test was used to compare continuous variables between survivor and non-survivor patient groups, and chi-square test to compare categorical variables between patient groups. Receiver operating characteristic (ROC) analyses were used to determine the capacity for 30-day mortality prediction by serum malondialdehyde levels at day 1, 4 and 8 of MMCAI. Area under curve (AUC), and sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predicted value and negative predicted value of serum malondialdehyde levels cut-offs for mortality prediction are showed with its 95% confidence intervals (CI). Optimal cut-off values at days 1, 4 and 8 were selected according to Youden J index. Multiple logistic regression was carried out to determine whether exists an association between serum malondialdehyde levels and 30-day mortality after to control for platelet count, lactic acid and GCS. P-values< 0.05 was the point considered to determine as statistically significant. SPSS 17.0 (SPSS Inc., Chicago, IL, USA), LogXact 4.1 (Cytel Co., Cambridge, MA), and NCSS 2000 (Kaysville, Utah) were the programs used for statistical analyses.

Results

In Table 1 is possible to see that significant differences were not found between patients groups, non-survivors (n = 34) and non-survivors (n = 34), in age, arterial hypertension, sex, COPD, diabetes mellitus, heart failure, chronic renal failure, temperature, lactic acid, sodium, bilirubin, creatinine, glycaemia, PaO2, PaO2/FIO2 ratio, leukocytes, haemoglobin, fibrinogen, INR, aPTT, APACHE-II, thrombolysis, volumen infarction, haemorrhagic transformation, midline shift, and descompresive craniectomy. However, lower GCS and platelets were found in non-survivor than in survivor patients.

Table 1 Clinical and biochemical characteristics of 30-day survivor and non-survivor MMCAI patients
Full size table

Serum MDA concentrations at days 1 (p < 0.001), 4 (p < 0.001), and 8 (p = 0.001) of MMCAI in non-survivor patients were higher than in survivor patients (Table 2 and Fig. 1).

Table 2 Receiver operation characteristic analysis using serum malondialdehyde levels at day 1, 4 and 8 of severe malignant middle cerebral artery infarction as predictor of mortality at 30 days
Full size table
Fig. 1
figure 1

Serum malondialdehyde levels at day 1, 4 and 8 of severe malignant middle cerebral artery infarction in 30-day survivor and non-survivor patients

Full size image

ROC curve analyses showed that serum malondialdehyde concentrations at days 1, 4, and 8 of MMCAI had an AUC (95% CI) to predict 30-day mortality of 0.77 (0.65–0.86; p < 0.001), 0.82 (0.69–0.91; p < 0.001) and 0.84 (0.70–0.93; p < 0.001) respectively. Table 2 showed sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predicted value and negative predicted value of serum malondialdehyde levels cut-offs at days 1, 4, and 8 of MMCAI for mortality prediction.

Multiple logistic regression an association between serum malondialdehyde levels> 2.87 mmol/mL and 30-day mortality (OR = 6.509; 95% CI = 2.095–20.222; p = 0.001) after to control for platelet count, lactic acid and GCS (Table 3).

Table 3 Multiple logistic regression analysis to predict 30-day mortality
Full size table

Discussion

The new findings of our study were that serum malondialdehyde levels during the first week of MMCAI could be used as biomarkers to mortality prediction.

Previously have been found higher circulating malondialdehyde levels during the first week of ischemic stroke in patients with worst neurological functional outcome [9,10,11,12], and at moment of ischemic stroke in non-survivor patients [13, 14]. Thus, the higher serum MDA levels during the first week of MMCAI observed in non-survivor patients in respect to survivor patients, and that those levels could be used as mortality prediction are two novel findings of our study.

We believed that those higher concentrations of serum malondialdehyde during the first week of MMCAI in non-survivor patients reflects a higher ROS production and lipid peroxidation in comparison to survivor patients, and the use of antioxidant agents could be a new therapeutic to explore in MMCAI patients. The administration of melatonin in animal models of ischemic stroke has been associated with a reduction of oxidation [18,19,20,21,22], specifically a reduction of malondialdehyde levels [21, 22], and even an increase of survival. In patients with ischemic stroke, the oral administration of different antioxidant vitamins (B2, B6, B12, C, E) during the first 14 days of stroke has been associated with lower plasma levels of malondialdehyde [23,24,25]. Thus, although we recognize that our study has the limitation that other oxidant state compounds were not reported, we think that all those findings could open the interest for study in patients with ischemic strike the oxidative stress and the potential role of antioxidant agents in your treatment.

Conclusions

The new findings of our study were that serum malondialdehyde levels during the first week of MMCAI could be used as biomarkers to mortality prediction.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

APACHE:

Acute Physiology and Chronic Health Evaluation

aPTT:

activated partial thromboplastin time

COPD:

Chronic Obstructive Pulmonary Disease

FIO2 :

fraction inspired of oxygen

GCS:

Glasgow Coma Scale

ICU:

Intensive Care Unit

INR:

International normalized ratio

PaO2 :

Pressure of arterial oxygen/fraction inspired oxygen

References

  1. Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EF. American Heart Association; American Stroke Association Stroke Council; Clinical Cardiology Council; Cardiovascular Radiology and Intervention Council; Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38:1655–711.

    Article  PubMed  Google Scholar 

  2. Radak D, Resanovic I, Isenovic ER. Link between oxidative stress and acute brain ischemia. Angiology. 2014;65:667–76.

    Article  CAS  PubMed  Google Scholar 

  3. Rodrigo R, Fernández-Gajardo R, Gutiérrez R, Matamala JM, Carrasco R, Miranda-Merchak A, Feuerhake W. Oxidative stress and pathophysiology of ischemic stroke: novel therapeutic opportunities. CNS Neurol Disord Drug Targets. 2013;12:698–714.

    Article  CAS  PubMed  Google Scholar 

  4. Manzanero S, Santro T, Arumugam TV. Neuronal oxidative stress in acute ischemic stroke: sources and contribution to cell injury. Neurochem Int. 2013;62:712–8.

    Article  CAS  PubMed  Google Scholar 

  5. Pradeep H, Diya JB, Shashikumar S, Rajanikant GK. Oxidative stress--assassin behind the ischemic stroke. Folia Neuropathol. 2012;50:219–30.

    Article  CAS  PubMed  Google Scholar 

  6. Warner DS, Sheng H, Batinić-Haberle I. Oxidants, antioxidants and the ischemic brain. J Exp Biol. 2004;207:3221–31.

    Article  CAS  PubMed  Google Scholar 

  7. Draper HH, Hadley M. Malondialdehyde determination as index of lipid peroxidation. Methods Enzymol. 1990;186:421431.

    Google Scholar 

  8. Dalle-Donne I, Rossi R, Colombo R, Giustarini D, Milzani A. Biomarkers of oxidative damage in human disease. Clin Chem. 2006;52:601–23.

    Article  CAS  PubMed  Google Scholar 

  9. Ozkul A, Akyol A, Yenisey C, Arpaci E, Kiylioglu N, Tataroglu C. Oxidative stress in acute ischemic stroke. J Clin Neurosci. 2007;14:1062–6.

    Article  CAS  PubMed  Google Scholar 

  10. Polidori MC, Cherubini A, Stahl W, Senin U, Sies H, Mecocci P. Plasma carotenoid and malondialdehyde levels in ischemic stroke patients: relationship to early outcome. Free Radic Res. 2002;36:265–8.

    Article  CAS  PubMed  Google Scholar 

  11. Silina EV, Rumiantseva SA, Bolevich SB, Men'shova NI. Course of free radical processes and prognosis of ischemic and hemorrhagic stroke. Zh Nevrol Psikhiatr Im S S Korsakova. 2011;111:36–42.

    CAS  PubMed  Google Scholar 

  12. Tsai NW, Chang YT, Huang CR, Lin YJ, Lin WC, Cheng BC, Su CM, Chiang YF, Chen SF, Huang CC, Chang WN, Lu CH. Association between oxidative stress and outcome in different subtypes of acute ischemic stroke. Biomed Res Int. 2014;2014:256879.

    PubMed  PubMed Central  Google Scholar 

  13. Kotur-Stevuljevic J, Bogavac-Stanojevic N, Jelic-Ivanovic Z, Stefanovic A, Gojkovic T, Joksic J, Sopic M, Gulan B, Janac J, Milosevic S. Oxidative stress and paraoxonase 1 status in acute ischemic stroke patients. Atherosclerosis. 2015;241:192–8.

    Article  CAS  PubMed  Google Scholar 

  14. Lorente L, Martín MM, Abreu-González P, Ramos L, Argueso M, Solé-Violán J, Riaño-Ruiz M, Jiménez A. Serum malondialdehyde levels in patients with malignant middle cerebral artery infarction are associated with mortality. PLoS One. 2015;10:e0125893.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Teasdale G, Jennett B. Assessement of coma and impaired conciousness. A practical scale. Lancet. 1974;2:81–4.

    Article  CAS  PubMed  Google Scholar 

  16. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–29.

    Article  CAS  PubMed  Google Scholar 

  17. Kikugawa K, Kojima T, Yamaki S, Kosugi H. Interpretation of the thiobarbituric acid reactivity of rat liver and brain homogenates in the presence of ferric ion and ethylediaminotetraacetic acid. Anal Biochem. 1992;202:249–55.

    Article  CAS  PubMed  Google Scholar 

  18. Tai SH, Hung YC, Lee EJ, Lee AC, Chen TY, Shen CC, Chen HY, Lee MY, Huang SY, Wu TS. Melatonin protects against transient focal cerebral ischemia in both reproductively active and estrogen-deficient female rats: the impact of circulating estrogen on its hormetic dose-response. J Pineal Res. 2011;50:292–303.

    Article  CAS  PubMed  Google Scholar 

  19. Li H, Wang Y, Feng D, Liu Y, Xu M, Gao A, Tian F, Zhang L, Cui Y, Wang Z, Chen G. Alterations in the time course of expression of the Nox family in the brain in a rat experimental cerebral ischemia and reperfusion model: effects of melatonin. J Pineal Res. 2014;57:110–9.

    Article  CAS  PubMed  Google Scholar 

  20. Bhattacharya P, Pandey AK, Paul S, Patnaik R. Melatonin renders by protein kinase C mediated aquaporin-4 inhibition in animal model of focal cerebral ischemia. Life Sci. 2014;100:97–109.

    Article  CAS  PubMed  Google Scholar 

  21. Balduini W, Carloni S, Perrone S, Bertrando S, Tataranno ML, Negro S, Proietti F, Longini M, Buonocore G. The use of melatonin in hypoxic-ischemic brain damage: an experimental study. J Matern Fetal Neonatal Med. 2012;25(Suppl 1):119–24.

    Article  CAS  PubMed  Google Scholar 

  22. Cuzzocrea S, Costantino G, Gitto E, Mazzon E, Fulia F, Serraino I, Cordaro S, Barberi I, De Sarro A, Caputi AP. Protective effects of melatonin in ischemic brain injury. J Pineal Res. 2000;29:217227.

    Article  Google Scholar 

  23. Ullegaddi R, Powers HJ, Gariballa SE. B-group vitamin supplementation mitigates oxidative damage after acute ischaemic stroke. Clin Sci (Lond). 2004;107:477–84.

    Article  CAS  Google Scholar 

  24. Ullegaddi R, Powers HJ, Gariballa SE. Antioxidant supplementation enhances antioxidant capacity and mitigates oxidative damage following acute ischaemic stroke. Eur J Clin Nutr. 2005;59:1367–73.

    Article  CAS  PubMed  Google Scholar 

  25. Ullegaddi R, Powers HJ, Gariballa SE. Antioxidant supplementation with or without B-group vitamins after acute ischemic stroke: a randomized controlled trial. JPEN J Parenter Enteral Nutr. 2006;30:108–14.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

This study was supported by a grant (OA18/011) from Fundación DISA a la Investigación Médica 2017 (Santa Cruz de Tenerife. Spain).

Authors’contributions

LL conceived, designed and coordinated the study, participated in acquisition and interpretation of data, and drafted the manuscript. MMM, RS, LR, MA, JSV, JJC, VGM participated in acquisition of data. PAG participated in blood determination levels. AJ participated in the interpretation of data. All authors revised the manuscript critically for important intellectual content, made the final approval of the version to be published, and were agreed to be accountable for all aspects of the work.

Funding

This study was supported by a grant (OA18/011) from Fundación DISA a la Investigación Médica 2017 (Santa Cruz de Tenerife. Spain). Funding did not influence in the study design, the collection, analysis, and interpretation of data, the manuscript writing, and the decision to submit it for publication.

Author information

Authors and Affiliations

  1. Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna –, 38320, Santa Cruz de Tenerife, Spain

    Leonardo Lorente

  2. Intensive Care Unit, Hospital Universitario Nuestra Señora de Candelaria, Crta del Rosario s/n, 38010, Santa Cruz de Tenerife, Spain

    María M. Martín

  3. Deparment of Phisiology, Faculty of Medicine, University of the La Laguna, 38320, Santa Cruz de Tenerife, La Laguna, Spain

    Pedro Abreu-González

  4. Deparment of Radiology, Hospital Universitario de Canarias, Ofra, s/n. La Laguna –, 38320, Santa Cruz de Tenerife, Spain

    Rafael Sabatel

  5. Intensive Care Unit, Hospital General La Palma, Buenavista de Arriba s/n, 38713, Breña Alta, La Palma, Spain

    Luis Ramos

  6. Intensive Care Unit, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibáñez n°17-19, 46004, Valencia, Spain

    Mónica Argueso

  7. Intensive Care Unit, Hospital Universitario Dr. Negrín, CIBERES, Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain

    Jordi Solé-Violán

  8. Intensive Care Unit, Hospital Insular, Plaza Dr. Pasteur s/n, ia-35016, Las Palmas de Gran Canar, Spain

    Juan J. Cáceres

  9. Research Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna –, 38320, Santa Cruz de Tenerife, Spain

    Alejandro Jiménez

  10. Deparment of Neurosurgery, Hospital Universitario de Canarias, Ofra, s/n. La Laguna –, 38320, Santa Cruz de Tenerife, Spain

    Victor García-Marín

Authors
  1. Leonardo Lorente
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. María M. Martín
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pedro Abreu-González
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rafael Sabatel
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Luis Ramos
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mónica Argueso
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jordi Solé-Violán
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Juan J. Cáceres
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Alejandro Jiménez
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Victor García-Marín
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Leonardo Lorente.

Ethics declarations

Ethics approval and consent to participate

This study was performed with the Institutional Review Board approval of the six participating hospitals and with the written informed consent of patient legal guardians. This study was carried out in the Intensive Care Units of the following hospitals: H. General de La Palma from Breña Alta, H. Universitario Dr. Negrín from Las Palmas de Gran Canaria, H. Insular from Las Palmas de Gran Canaria, H. Universitario Nuestra Señora de Candelaria from Santa Cruz de Tenerife, H. Clínico Universitario de Valencia from Valencia, and H. Universitario de Canarias from La Laguna. The study adheres to the World Medical Association Declaration of Helsinki regarding ethical conduct of research involving human subjects.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lorente, L., Martín, M.M., Abreu-González, P. et al. Non-survivor patients with malignant middle cerebral artery infarction showed persistently high serum malondialdehyde levels. BMC Neurol 19, 238 (2019). https://doi.org/10.1186/s12883-019-1479-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12883-019-1479-z

Keywords

  • Malondialdehyde
  • Ischemic stroke
  • Patients
  • Mortality
  • Prognosis

BMC Neurology

ISSN: 1471-2377

Contact us