Investigation of Vaspin L

evel in Patients with AcuteIschemic Stroke

Hasan S. Cura, MD,* Hasan H. €Ozdemir, MD,† Caner F. Demir, MD,‡

Serpil Bulut, MD,‡ Nevin _Ilhan, MD,x and Mehmet Fatih Inci, MDjj

From the *Neurolog

†Neurology Clinics, Bism

of Neurology, Fırat Univ

of Biochemistry, Fırat

jjDepartment of Radiolo

Kahramanmaras, Turkey

Received January 11,

accepted March 19, 2013

Conflict of interest: Th

Address corresponden

Clinics, Bismil State Ho

drhasanh@gmail.com.

1052-3057/$ - see front

� 2013 by National Str

http://dx.doi.org/10.1

Journal of Stroke and C

Background: Cerebrovascular event is a clinical condition characterized by symp-

toms and findings pertaining to loss of focal cerebral function because of the vas-

cular causes. Atherosclerosis has a forefront role in the pathogenesis of stroke.

Inflammation has an important place in the formation of atherogenesis and ath-

erosclerosis. Visceral adipose tissue–derived serpin (vaspin) is a new adipokine,

which is identified recently, associated with obesity and diabetes and also has

a proinflammatory characteristic. This study was intended to investigate the re-

lation between vaspin and stroke and stroke and other risk factors. Methods: Atotal of 50 patients with stroke, as 28 men (56%) and 22 women (44%), and a total

of 50 healthy individuals, as 25 men (50%) and 25 women (50%), were enrolled

in the study. Blood samples were taken in the acute period (first 48 hours) in the

patient group, and serum vaspin levels were measured. Vaspin level was also mea-

sured in the control group. The association of vaspin with the lipid parameters,

gender, and the severity of internal carotid artery (ICA) stenosis in the patient

group was evaluated. Stenotic plaques in ICAwere classified as normal, mild (ste-

nosis under 50%), moderate (stenosis 50%-69%), severe (stenosis 70%-99% to pre-

occlusion), and occlusion. Results: No statistically significant difference was

found between 2 groups in terms of age and gender (P . .05). Vaspin levels were

found to be significantly higher in the patient group (164.736 153.76 ng/mL) com-

pared with the control group (116.21 6 34.60 ng/mL) (P , .05). However, no rela-

tion was established between vaspin level and the severity of ICA stenosis.

Conclusions:Vaspin levels have been shown to increase in acute ischemic stroke pa-

tients. The increased vaspin levels may vary depending on several factors in acute

period of ischemic stroke. Key Words: Vaspin—ischemic stroke—carotid artery

stenosis—cerebrovascular event—carotid artery ultrasound.

� 2013 by National Stroke Association

y Clinics, Turhal State Hospital, Tokat;

il State Hospital, Diyarbakır; ‡Department

ersity Medical School, Elazı�g; xDepartment

University Medical School, Elazı�g; and

gy, S€utc€u _Imam University Medical School,

.

2013; revision received March 15, 2013;

.

e authors declared no conflicts of interest.

ce to Hasan H. €Ozdemir, MD, Neurology

spital, Diyarbakır 21500, Turkey. E-mail:

matter

oke Association

016/j.jstrokecerebrovasdis.2013.03.023

erebrovascular Diseases, Vol. -, No. - (---

Introduction

Stroke is the third most common cause of death around

the world, after coronary heart disease and cancers. Prev-

alence of this disease,which generally occurs in the elderly

patients, increases along with the extension of average

lifetime. The most important cause of ischemic strokes is

atherothrombotic events.1 The role of atherosclerosis in is-

chemic strokes varies between 27% and 43%.2

Some studies have found that adipokines are released

at the atherosclerotic plaques, and they show their local

and endocrinal effects on lesions.3 Visceral adipose

tissue–derived serpin (vaspin) is an important and

a new adipocytokine with regulation characteristics in

), 2013: pp 1-4 1

H.S. CURA ET AL.2

glucose and lipid mechanism. The correlation of its serum

concentrations with the tests regarding obesity and lipid

distribution gives rise to the thought that vaspin is

a new molecule candidate for causing obesity-related

atherosclerosis.4

The objective of our study was to investigate whether

the plasma vaspin level has a predictive importance diag-

nostically in the acute period of ischemic cerebrovascular

disease and its relation between carotid stenosis level in

the patient group.

Materials and Methods

Fifty patients, who admitted to the Neurology Clinic of

our hospital within the first 48 hours with the manifesta-

tion of acute ischemic stroke, diagnosed with ischemic

stroke, hospitalized, and followed between March 2010

and January 2012 were enrolled in this study. And the

control group consisted of 50 healthy subjects having no

previous cerebrovascular disease, compatible with the pa-

tient group in terms of age and gender. Approval was ob-

tained from the Firat University Medical Faculty Clinical

Research Ethics Committee for the study (number: 21).

Diagnosis of acute ischemic stroke was put by at least 2

neurologists and 1 radiologist in the patients, who had

acute focal neurological deficit lasting more than 24 hours

and for whom there were no other reason except cerebro-

vascular disease that could cause such neurological

deficit, through a complete neurological assessment in-

cluding neuroradiological imaging such as cranial com-

puted tomography and/or cranial magnetic resonance

imaging (MRI).

In all patients, physical examination and neurological

examination, complete blood count, liver and kidney

function tests, electrocardiogram, electrolyte levels and

lipid profile, cranial computed tomography, cranial

MRI, and diffusion MRI with carotid system color

Doppler ultrasonography (CDUS) examination were per-

formed.

The patients with recovering neurological findings

within 24 hours, the patients diagnosedwith hemorrhagic

cerebrovascular disease through clinical and neuroradio-

logical assessment, and the patients with previous ische-

mic stroke were excluded from the study.

The patients with heart disease, which could lead to

cardioembolism such as atrial fibrillation, severe heart

failure, and valvular heart disease, malignant hyperten-

sion, Cushing syndrome or obesity secondary to any of

the congenital diseases, central nervous system vasculitis,

congenital vascular disease, trauma, dissection, and cere-

bral venous thrombosis; the patients with thyroid and

kidney dysfunction and liver failure; and the patients

with local and systemic infections were excluded from

the study.

For evaluating the serum vaspin level of within the first

48 hours, the patients diagnosed with acute ischemic

stroke and hospitalized, venous blood sample of 5 cc

were collected. Blood samples were centrifuged at 1500g

for 10 minutes to get the serums. The serums obtained

were put in 2 separate eppendorf tubes for each patient

and stored at 220 �C by avoiding repeated freezing–

thawing procedures until the analysis. Same procedure

was also applied to the cases selected for the control

group.

Serum vaspin levels were studied by using

Adipobiotech-branded Human Visceral Adipose Tissue–

Derived Serine Protease Inhibitor (VASPIN) ELISA kit

(Adipo Bioscience, Inc., Santa Clara, CA). Informed con-

sent forms were requested from the patients and the

healthy individuals before the procedures.

Carotid Artery CDUS Technique

Examinations were performed by using 10-MHz linear

probe at General Electric Logiq-9 model CDUS (General

Electric, Milwaukee, OH). As the patients were in supine

position, necks were at extension, and the head was fac-

ing toward the opposite of the examination side, 2-sided

carotid arteries were examined from supraclavicular re-

gion through mandibular angle by using power Doppler

ultrasonographic examination. First, presence of plaque

was investigated by B-mode examination. When plaque

was established, the site, size, and surface characteristics

of the plaque were determined. CDUS examination was

performed in the longitudinal and transverse plane in

color mode. Spectral waveform was taken in the main ca-

rotid artery from about 2 cm proximal to the bifurcation

and center of the vessel, just distal to the ICA bulb.

Flow was measured with a 30�-60� angle to the lumen

as a standard. Peak systolic velocity (PSV) and end-

diastolic velocity in ICA and main carotid artery were re-

corded. PSV ratios (PSV in ICA/common carotid artery)

were calculated over these values. For stenosis grading

(%) of the plaques examined, Society of Radiologist in

Ultrasound criteria were used.5 Stenotic plaques in ICA

were classified as normal, mild (stenosis under 50%),

moderate (stenosis 50%-69%), severe (stenosis 70%-99%

to preocclusion), and occlusion.

Statistical Analysis

For statistical analyses, the statistics program SPSS 12.0

was used. Results were submitted as 6standard devia-

tion. Student t test was used for comparing parametric

data between the groups, and chi-square test was used

for comparing categorical data. Normality of the paramet-

ric data distribution was evaluated by Kolmogorov–

Smirnow test. For the parameters showing no normal

distribution, logarithmic conversions were applied before

the statistical analyses. Difference of the nonparametric

data among more than 2 groups was evaluated by

Kruskal–Wallis test. In all statistical assessments, P value

less than .05 was considered statistically significant.

Table 1. Vaspin levels according to the Doppler stenosis

severity in the patient group (Kruskal–Wallis test)

Doppler USG

(stenosis severity) N Vaspin (ng/mL) P

0%-50% stenosis 44 171.53 6 162.88 ..05

50%-70% stenosis 3 121.54 6 2.90

70%-99% stenosis 3 108.08 6 14.58

Occlusion —

Abbreviations: USG, ultrasonography; vaspin, visceral adipose

tissue–derived serpin.

INVESTIGATION OF VASPIN LEVEL IN PATIENTS WITH ACUTE ISCHEMIC STROKE 3

Results

A total of 100 people, as 50 patients diagnosed with

cerebrovascular event and 50 healthy individuals consist-

ing the control group, were enrolled in the study.

Of patients with stroke, 28 were men (56%) and 22 were

women (44%). Of the control group, 25 were men (50%)

and 25 were women (50%). No significant gender differ-

ence was found between patient group and control group.

The mean age of the patient group was 69.58 6 12.21

(40-97) years compared with 67.06 6 10.19 (42-88) years

in the control group. No statistically significant difference

was found between the 2 groups (P . .05).

There were 15 (30%) diabetic, 17 (34%) hypertensive,

and 7 (14%) obese patients in the stroke group.6,7 There

were 14 (28%) diabetic, 15 (30%) hypertensive, and 6

(12%) obese patients in the control group. There was no

statistically significant difference between groups.

Mean serum vaspin levels were found to be 164.73 6

153.76 ng/mL in the stroke group compared with

116.216 34.60 ng/mL in the control group. Serum vaspin

levels were higher in the stroke group than the control

group. The difference between the 2 groups reached the

statistically significant level (P , .05).

When considered the relation of serum vaspin levels

with the gender in the patient group, the mean value

was 163.53 6 165.77 ng/mL in men compared with

166.26 6 140.81 ng/mL in women. No statistically signif-

icant difference was found between serum vaspin levels

of men and women (P . .05).

Mean serum vaspin levels were found to be 170.73 6

123.76 ng/mL in the diabetic stroke group compared

with 126.21 6 34.60 ng/mL in the diabetic control group.

The difference between the 2 groups reached the statisti-

cally significant level (P , .05).

Mean serum vaspin levels were found to be 160.73 6

35.76 ng/mL in the hypertensive stroke group compared

with 118.21 6 32.60 ng/mL in the hypertensive control

group. The difference between the 2 groups reached the

statistically significant level (P , .05).

Mean serum vaspin levels were found to be 172.73 6

35.76 ng/mL in the obese stroke group compared with

130.216 12.60 ng/mL in the obese control group. The dif-

ference between the 2 groups reached the statistically sig-

nificant level (P , .05).

No significant relation was established between the se-

verity of ICA stenosis (stenosis 0%-50%, 50%-70%, and

above 70%) identified at Doppler ultrasonography and

the serum vaspin levels of the patient group (P . .05)

(Table 1).

Discussion

Stroke is an important cause of mortality andmorbidity

in adults. Because more than half of the people who had

stroke and survived become dependent on others in their

daily activities, it is the most common cause of long-term

neurological disability in adults.8 One of the most impor-

tant causes of ischemic strokes is atherosclerosis.1 Athero-

sclerosis is an inflammatory disease, characterized by

atherosclerotic plaques because of accumulation of lipids

on extracellular matrix and active smooth muscle cell sur-

face in the arterial wall. These atherosclerotic plaques

contribute to the formation of ischemic diseases such as

coronary artery disease, transient ischemic attack, and

stroke.9

Vaspin is an important and a new adipocytokine with

regulation characteristics in glucose and lipid mecha-

nism. Vaspin is considered to be a member of the ser-

pins.10 Vaspin is a member of serine protease family,

identified recently, and is known to be expressed in the

visceral adipose tissue with obesity and when insulin

concentrations reach the peak level in Otsuka Long–

Evans Tokushima Fatty rats.11 Vaspin from adipose

tissue–origin factors is considered to be an important con-

tributing factor in the relation between visceral adiposity

and atherosclerosis.11

There are studies suggesting that there is a relation be-

tween the serum levels of adiponectines and gender.

Youn et al4 reported that serum vaspin levels showed dif-

ference between men and women by enzyme-linked im-

munosorbent assay method developed by them. And in

our study, serum vaspin levels showed no significant dif-

ference between the genders.

Elevated serum concentrations of vaspin were associ-

ated with obesity and impaired insulin sensitivity,

whereas type 2 diabetes was reported to be against this re-

lation.4 It is not known what kind of a relation there is

among the serum vaspin levels, insulin sensitivity, and

glucose metabolism in humans.10 It has been reported

that human vaspin lipid messenger RNA expression is

specific to the lipid reservoir and its concentrations in se-

rum increase in obesity.12

It was suggested that adipose tissue–originated factors,

including also adipokines, in obese patients might con-

tribute to the premature and accelerated atherosclerosis.13

Although there are a number of studies investigating

the relation between vaspin levels and obesity, diabetes,

and cardiovascular disease in the literature, there are

H.S. CURA ET AL.4

limited number of studies investigating the relation

between cerebrovascular diseases and vaspin. In a study

by Aust et al,14 no relation was found between carotid

artery stenosis and serum vaspin concentration; however,

it was shown that low concentration of serum vaspin was

correlated with recent ischemic event in the patients with

carotid artery stenosis. Although they could not conclude

from these findings that serum vaspin levels might cause

atherosclerosis, considering the negative relation between

vaspin and blood pressure, they suggested that vaspin

might be associated with coronary artery disease and

cerebral stroke through hypertension.

In our study, the relation between vaspin level and

carotid stenosis in the patient group was evaluated.

Even though there was not any significant difference in

vaspin levels between the groups according to the sever-

ity of stenosis, it has been observed that as the stenosis

ratio increase, vaspin levels decrease gradually.

This study has some limitations. First, the number

of the patients that fall into the groups other than the

0%-50% stenosis group is quite small, and second, we

did not compare vaspin levels of our study population

with the area of infarction.

In the literature, there was not any study measuring the

serum vaspin level in the patients with acute ischemic

stroke. In our study, vaspin level in the patient group

was found to be higher compared with the control group,

and the difference between the 2 groups reached the sta-

tistically significant levels. And no statistically significant

difference was found between carotid stenosis severity

and serum vaspin levels in the patient group. Conse-

quently, vaspin levels may vary depending on several fac-

tors, and vaspin levels increase in acute period of

ischemic stroke.

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