|Year : 2022 | Volume
| Issue : 2 | Page : 33-39
Serum homocysteine in intracerebral hemorrhage: A savior or a destroyer?
Debabrata Chakraborty1, Sadanand Dey1, Sanjay Bhaumik1, Aditya Choudhary1, Kishalaya Karan1, Pradipta Bhattacharjee1, Priyanjita Sen1, Mohuya Mukherjee1, Gobinda Pramanick2, Nirmalya Ray2, Payel Biswas2, Jayanta Roy3, Satya Narayan Singh4, Binod Kumar Singhania4, Biswajit Sengupta4, Kajal Das4, Gopal Acharya4, Bhaskar Ukil4, Rahul Ghosh4
1 Department of Neurology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
2 Department of Radiology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
3 Department of Neurology, Institute of Neurosciences, Kolkata, West Bengal, India
4 Department of Neurosurgery, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
|Date of Submission||08-Apr-2022|
|Date of Decision||05-May-2022|
|Date of Acceptance||08-May-2022|
|Date of Web Publication||24-May-2022|
Dr. Debabrata Chakraborty
64/4A/9, Beliaghata Main Road, Kolkata - 700 010, West Bengal
Source of Support: None, Conflict of Interest: None
Objectives: Intracerebral hemorrhage (ICH) is more common in the Indian subcontinent compared to the Western world and associated with significant morbidity and mortality. Hence, all possible modifiable factors should be searched and steps taken so that a single opportunity is not missed in preventing such a catastrophe. The aim of the study is to find out whether homocysteine and Vitamin B12 are related to ICH. Materials and Methods: We included acute ICH patients of 18 years and above who came to our institute and got admitted in 5 months (September 2021–January 2022). Our team noted the demographics, National Institutes of Health Stroke Scale (at admission and discharge) and other clinical parameters. Volume and site of the intracerebral hematoma (from the initial computed tomography [CT] scan of the brain) were noted. The outcome and prognostic markers like Modified Rankin Scale (mRS) at discharge, MRS at 3 months (also MRS at admission) and ICH score were calculated. The blood parameters, including serum homocysteine and Vitamin B12 level, were noted post admission in hospital. Results: We found out of 44 ICH patients; ten patients had hyperhomocysteinemia (HHcy): 22.72%. We detected significant correlation between HHCy with ICH score (inverse relationship) and dyslipidemia (direct relationship). Conclusion: We found an inverse correlation between serum homocysteine level and ICH score, which shows a short-term (1 month) prognosis. This might hint that homocysteine might have a protective role to play in ICH. However, we probably need larger study population to find a correlation strong enough so that we can make a stronger conclusion.
Keywords: Hyperhomocysteinemia, Intracerebral hemorrhage score, intracerebral hemorrhage
|How to cite this article:|
Chakraborty D, Dey S, Bhaumik S, Choudhary A, Karan K, Bhattacharjee P, Sen P, Mukherjee M, Pramanick G, Ray N, Biswas P, Roy J, Singh SN, Singhania BK, Sengupta B, Das K, Acharya G, Ukil B, Ghosh R. Serum homocysteine in intracerebral hemorrhage: A savior or a destroyer?. J Prim Care Spec 2022;3:33-9
|How to cite this URL:|
Chakraborty D, Dey S, Bhaumik S, Choudhary A, Karan K, Bhattacharjee P, Sen P, Mukherjee M, Pramanick G, Ray N, Biswas P, Roy J, Singh SN, Singhania BK, Sengupta B, Das K, Acharya G, Ukil B, Ghosh R. Serum homocysteine in intracerebral hemorrhage: A savior or a destroyer?. J Prim Care Spec [serial online] 2022 [cited 2023 Jan 28];3:33-9. Available from: https://www.jpcsonline.org/text.asp?2022/3/2/33/345903
| Introduction|| |
Intracerebral hemorrhage (ICH) accounts for 10%–15% of all strokes., ICH is more severe and disabling than ischemic stroke with highest mortality rate of all., Although ischemic stroke is much more common all over the world, hemorrhagic stroke is more common in Indian subcontinent (compared to the Western world). Prevention is better than cure and we should not keep any stone unturned to prevent such a happening. Hence, we wanted to search more about this type of stroke to find any new preventable/treatable solution. The risk factors of intracerebral bleed mainly include hypertension, dyslipidemia, diabetes mellitus, and smoking.,,, However, search should remain for other modifiable (s). The test should be affordable and, if positive, should be treatable (at least to a considerable extent). Association of serum homocysteine and hemorrhagic stroke had always been controversial. Hence, we tried to find an association between different demographics of hemorrhagic stroke patients with increased serum homocysteine and its associated serum Vitamin B12 level. Homocysteine level is elevated in people with a strict vegetarian diet. Our study population included people with mixed diet patterns (vegetarian and nonvegetarian) and this probably neutralized the dietary influence on serum homocysteine levels.
Endoplasmic reticulum (ER) stress is an important factor causing cell death after ICH. Under stressful conditions, the ER undergoes aggregation of misfolded and unfolded proteins, which finally elicits unfolded protein response (UPR). The role of UPR is to restore normal function of the ER; without it, the cell dies They have reported that homocysteine causes protein misfolding in the ER and activates the UPR, leading to increased expression of the ER stress-response genes, GRP78/BiP and GADD153., Thus, homocysteine may be a savior in this context. We tried to find an association between homocysteine and ICH, if any. Specially attempted to look into a prognostic relationship.
| Materials and Methods|| |
We detected six candidates having Vitamin B12 deficiency, i.e., <200 μg% (1 female and five males), which made up 13.63% of the total.
We included acute ICH patients of 18 years and above who came to our institute and got admitted to the neurology, neurosurgery, and medicine department in 5 months (September 2021–January 2022).
Our team noted the detailed demographics of the patient (including age, sex, risk factors such as hypertension, diabetes, dyslipidemia, smoking, and alcohol consumption). We noted the standard scales: Glasgow Coma Scale (GCS) during admission, NIH stroke scale/score National Institutes of Health Stroke Scale (NIHSS) during admission and discharge. Our team noted other clinical parameters such as dysarthria, aphasia, and dysphagia (GUSS scores). We calculated the ICH volume of every patient. Among the radiological parameters, we noted the site of blood (anatomical location) and volume of blood from the computed tomography (CT) scan of the brain done on the day of ictus. The team recorded mRS at baseline, discharge from hospital and at 3 months.
We collected superficial venous blood for measurement of homocysteine (Hcy) level. Chemiluminescence assay method assessed serum Hcy in one morning after the hospital admission with ICH with at least 8 h of fasting. We defined Hyperhomocysteinemia (HHcy) levels higher than 15 mmol/l as high homocysteine in the study. The team tested blood parameters: complete blood count, serum Vitamin B12 level, liver function test, renal function tests, fasting lipid profile, blood sugar parameters (fasting blood sugar, post prandial and HBA1C), and thyroid function test.
Low Vitamin B12 concentration contributes to almost 28% of patients with HHcy, while low folate concentration contributes to approximately 2% of patients with HHcy. Hence, keeping in mind limited resources in our setup, we chose serum Vitamin 12 levels along with homocysteine levels to find the relationship (if any).
We deliberately excluded patients having coagulation abnormalities, aneurysmal and vascular malformation-related bleed, tumor bleed, and cerebral amyloid angiopathy. This is because the mechanism of bleed in these scenarios is different and so is the recurrence rate and outcome.
We tried to exclude other associative factors which might act as a confounding factor in reaching our target. The team deliberately drew blood for Hcy 2–3 days after the ictus so that the acute inflammatory reaction causing HHcy (immediately post stroke) did not influence its level.
Data management and statistical analysis
Categorical variables were expressed as the number of patients and percentage of patients and compared using Pearson's Chi-square test for independence of attributes/Fisher's exact test.
Continuous variables were expressed as Mean ± Standard Deviation and compared using Mann–Whitney U-test as the data did not follow the normal distribution.
P < 0.05 was considered statistically significant in each case.
| Results|| |
We included 44 total hemorrhagic patients whose all details we could record (17 females and the rest males). The study population included mainly people from the capital city of Kolkata, West Bengal, India, and its surroundings. Five out of sixteen patients who were smokers (36.4% of the total study population) had high homocysteine levels. Forty-two of 44 patients had hypertension (95.45%) and 24 out of 44 patients had been diabetic (54.54%). Seventeen out of 44 patients had dyslipidemia (38.63%). We tried to find an association between Vitamin B12 and homocysteine level of an individual patient with demographic, clinical, and radiological parameters. Ten out of 44 patients had HHcy (22.72%); (three females and seven males) [Figure 1]. This agreed to study, which found increased homocysteine levels in patients who develop ICH compared to healthy controls. [12,13]
|Figure 1: Distribution homocysteine and Vitamin B12 level among ICH patients. ICH: Intracerebral hemorrhage|
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We detected six candidates having Vitamin B12 deficiency, i.e., <200 μg% (1 female and five males), which made up 13.63% of total. Four (2 males and 2 females) that is 9% of the total had borderline Vitamin B12 deficiency (200–300 μg%), rest patients had sufficient Vitamin B12 levels. We had only one pure vegetarian patient and the rest enjoyed mixed diet pattern. Our only pure vegetarian patient had normal Vitamin B12 levels and homocysteine levels.
In the clinical parameters: patients mostly presented with moderate (NIHSS 5-15) and moderate to severe (NIHSS16-20) NIHSS score: 55% and 36%, respectively. They got discharged mostly with moderate (66%), followed by minor deficits (30%).
Eighty-two82 percentage of patients had dysarthria: 52% had moderate dysphagia, while 18% had severe dysphagia (GUSS score of patients in supplementary file). All except one required a feeding tube initially. About 36% of total patients had aphasia during presentation.
During admission, most patients had the Modified Rankin Scale (mRS) 1 (59%), followed by mRS 2 and 3: 25% and 13%, respectively. The discharge mRS mostly remained on the higher side: 70% had mRS 5, while 25% had mRS 4. We noted mRS at 3 months and found out mRS towards better trend. We arranged mRS at 3 months with decreasing frequency: mRS 4 (41%), mRS 5 (36%) and mRS 3 (16%). There was no significant difference in change of mRS between (surgical) intervention and nonintervention group.
Amongst the radiological findings, there was hemorrhage in the subcortical region in 35 patients (80%), cortical lesion in four (9%) patients and both cortical and subcortical hemorrhage was present in five patients (11%).
Intracerebral hematoma detection revealed 54.5% having up to 30 ml of blood; 25% had between 30 ml and 60 ml of blood, 11% between (61 ml–90 ml of blood) and the rest above 90 ml. Most patients had zero ICH score (30%), followed by ICH score of 1 (25%) and the lowest population was patients with ICH score of 4 (9%).
We tried to find an association between serum Vitamin B12 and homocysteine level with:
- Diabetes, hypertension, dyslipidemia, smoking, alcohol
- NIHSS at admission and discharge, MRS at admission, during discharge and at 3 months, stroke site (cortical vs. subcortical), dysarthria, dysphagia (mild, moderate, and severe), aphasia
- ICH volume, GCS during admission, intraventricular bleed, and ICH score.
We detected a statistically significant association for both serum Vitamin B12 level and HHcy with ICH. We observed a similar association between vitamin B12 level and following parameters: NIHSS during discharge [Table 1], modified Rankin Scale during admission [Table 2], alcohol intake, diabetes [Table 3]. We strongly associated HHcy with dyslipidaemia [Table 4] and ICH score [Table 5]. We strongly associated HHcy with dyslipidemia and ICH score. We found that 70% of patients with HHcy having lower ICH score (ICH score of 1) and nobody had a score of 4 or more [Figure 2]. This shows higher homocysteine level is associated with a favorable outcome. This is not with the notion with the study, which proved: high Hcy level was independently associated with a poorer 3 months prognosis and higher mortality within 1 year in patients with ICH.
|Table 1: Association between Vitamin B12 and National Institutes of Health Stroke Scale at discharge|
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|Table 2: Association between Vitamin B12 and Modified Rankin Scale at admission|
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|Table 5: Association between homocysteine and intracerebral hemorrhage score|
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|Figure 2: Correlation between homocysteine and ICH score. ICH: Intracerebral hemorrhage|
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We detected a significant correlation (man Whitney test) between dyslipidemia and homocysteine level: Those with dyslipidemia had a median homocysteine level of 13.40 (minimum: 5.43, maximum: 22.70) [Figure 3]. Those without dyslipidemia had a median homocysteine level of 11.50 (minimum: 2.50 and maximum: 31.20).
There was a strong correlation between Vitamin B12 level and alcohol intake also: those on alcohol intake had median Vitamin B12 level of 411 (minimum:131, maximum 970) and those without alcohol intake had a median Vitamin B12 level of 778 (minimum:153, maximum:2000). All details are in the supplementary files.
| Discussion|| |
Homocysteine is an intermediate sulfhydryl-containing amino acid. The liver synthesizes it by removal of the methyl group from methionine. Scientists have detected Hcy in patients with a nutritional deficiency of B12, folic acid, and pyridoxine. It is present in genetic diseases where there is a deficiency of cystathionine beta-synthase enzyme (CβS) or there is a mutation in the enzyme 5,10-methylenetetrahydrofolate reductase (MTHFR). High methionine content in diet, smoking and a sedentary lifestyle may increase homocysteine levels.,,, HHcy induces a neuroinflammatory process because of its ability to react with cytokines in the brain, leading to increased permeability of the blood–brain barrier., There is enough evidence that why they associate plasma Hcy levels with higher mortality rates from ischemic stroke, cardiovascular diseases, and peripheral artery disease.,,, However, there is still not enough evidence that we can associate HHcy with ICH.
Hence, in this prospective and retrospective study, we tried to find whether there is any such association between serum homocysteine and Vitamin B12 levels with different parameters in relation to ICH.
As expected, patients with large intracranial hematoma had higher NIHSS and worse mRS during discharge and at 3 months. However, we did not find a correlation between homocysteine level and Vitamin B12 level with either severity of stroke or outcome of stroke. However, the positive association (Chi-square test) between ICH with both homocysteine level and Vitamin B12 level shows there must be a pathogenic connection between them.
There is a positive correlation between homocysteine level and dyslipidemia in our study, as reported before. They have found a correlation between positive alcohol intake and low Vitamin B12 level, like in our study.
However, the new interesting finding was the association between ICH score and HHcy. The ICH score had an important correlation with the mortality of ICH patients. The inverse relationship between the two hints that HHcy might be a protective reflex of human nature as it prevents apoptosis by promoting regeneration of the insulted ER.
This is the first report where we tried to relate ICH score with homocysteine in patients with ICH and further studies are required.
We searched for a relationship between HHcy with individual components of the ICH score as well. They found HHcy contributes to larger hematoma volume. However, we did not find any association between these two parameters. They found an inverse relationship between HHcy and GCS score, but we did not. As much as our knowledge, there is no study correlating the incidence of intraventricular hemorrhage with Hcy or Vitamin B12. We could not get any association between HHcy and intraventricular bleed, but an association was found between vitamin B12 level and intraventricular hemorrhage.
Vitamin B12 level, which we can do even in a rural part of the country, has shown to have a correlation with the modified Rankin scale at baseline and NIHSS during discharge. They have correlated Vitamin B12 level with ischemic stroke outcome, but data are still lacking regarding the same association in the case of hemorrhagic stroke. Another interesting point in our study was that the Vitamin B12 deficiency was not an exclusive association with vegetarian diet, rather equally distributed among vegetarian and nonvegetarian candidates. This shows probably other factors, including genetic predisposition, might play an important role. Vitamin B12 was more sufficient in diabetic patients. This is probably because many of them were on vitamin supplements for neuropathy, which is more common in this group.
| Conclusion|| |
Intracerebral bleed is commoner in the Asian population compared to the West and carries very high morbidity and mortality. Our study shows that simple parameters may show a relationship with ICH which may be helpful in management and prognostication. Future studies are required to evaluate these factors and more so that we can understand, prevent, and treat this devastating disease better.
Limitations of our study
We did not have a large sample size; so, making any strong comment or recommendation is not possible from our result. Our study, though, had prospective and retrospective design; significant number of patients was in the retrospective group, which may cause the biased result. Though we waited for sufficient time, we could not analyze the effect of the acute stress reaction of ICH on plasma Hcy levels. We had insufficient data about Hcy levels before the onset of the ICH and later in the course of illness. Hence, a similar study with a larger sample size is required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cai X, Rosand J. The evaluation and management of adult intracerebral haemorrhage. Semin Neurol 2015;35:638-45.
Zheng H, Chen C, Zhang J, Hu Z. Mechanism and therapy of brain edema after intracerebral haemorrhage. Cerebrovasc Dis 2016;42:155-69.
Wang X, Dong Y, Qi X, Huang C, Hou L. Cholesterol levels and risk of haemorrhagic stroke: A systematic review and meta-analysis. Stroke 2013;44:1833-9.
Tsai CF, Anderson N, Tomas B, Sudlow CL. Comparing risk factor profiles between intracerebral haemorrhage and ischemic stroke in Chinese and White populations: Systematic review and meta-analysis. PLoS One 2016;11:e0151743.
Boulouis G, Morotti A, Goldstein JN, Charidimou A. Intensive blood pressure lowering in patients with acute intracerebral haemorrhage: Clinical outcomes and haemorrhage expansion. Systematic review and meta-analysis of randomised trials. J Neurol Neurosurg Psychiatry 2017;88:339-45.
Woo D, Sauerbeck LR, Kissela BM, Khoury JC, Szaflarski JP, Gebel J, et al.
Genetic and environmental risk factors for intracerebral hemorrhage: Preliminary results of a population-based study. Stroke 2002;33:1190-5.
Mohammed Thangameeran SI, Tsai ST, Hung HY, Hu WF, Pang CY, Chen SY. A role for endoplasmic reticulum stress in intracerebral hemorrhage. Cells 2020;9:750.
Outinen PA, Sood SK, Pfeifer SI, Pamidi S, Podor TJ, Li J, et al.
Homocysteine-induced endoplasmic reticulum stress and growth arrest leads to specific changes in gene expression in human vascular endothelial cells. Blood 1999;94:959-67.
Outinen PA, Sood SK, Liaw PC, Sarge KD, Maeda N, Hirsh J, et al.
Characterization of the stress-inducing effects of homocysteine. Biochem J 1998;332 (Pt 1):213-21.
Guo H, Chi J, Xing Y, Wang P. Influence of folic acid on plasma homocysteine levels & arterial endothelial function in patients with unstable angina. Indian J Med Res 2009;129:279-84.
] [Full text]
Yajnik CS, Deshpande SS, Lubree HG, Naik SS, Bhat DS, Uradey BS, et al.
Vitamin B12 deficiency and hyperhomocysteinemia in rural and urban Indians. J Assoc Physicians India 2006;54:775-82.
Lahiri KD, Datta H, Das HN. Reference interval determination of total plasma homocysteine in an Indian population. Indian J Clin Biochem 2014;29:74-8.
Hultdin J, Van Guelpen B, Winkvist A, Hallmans G, Weinehall L, Stegmayr B, et al.
Prospective study of first stroke in relation to plasma homocysteine and MTHFR 677C>T and 1298A>C genotypes and haplotypes –
Evidence for an association with hemorrhagic stroke. Clin Chem Lab Med 2011;49:1555-62.
Wang D, Wang W, Wang A, Zhao X. Association of severity and prognosis with elevated homocysteine levels in patients with intracerebral hemorrhage. Front Neurol 2020;11:571585.
Zhou Z, Liang Y, Qu H, Zhao M, Guo F, Zhao C, et al.
Plasma homocysteine concentrations and risk of intracerebral hemorrhage: A systematic review and meta analysis. Sci Rep 2018;8:2568.
Chen SF, Cui CL, Wu P, Xie NZ. Relationship of serum homocysteine level with nutritional status and HbA1c level in elderly inpatients. Int J Clin Exp Med 2013;6:779-84.
Mandaviya PR, Stolk L, Heil SG. Homocysteine and DNA methylation: A review of animal and human literature. Mol Genet Metab 2014;113, 243-14.
Bhatia P, Singh N. Homocysteine excess: Delineating the possible mechanism of neurotoxicity and depression. Fundam Clin Pharmacol 2015;29:142-8.
Dinç N, Yücel SB, Taneli F, Sayın MV. The effect of the MTHFR C677T mutation on athletic performance and the homocysteine level of soccer players and sedentary individuals. J Hum Kinet 2016;51:61-9.
Kamat PK, Vacek JC, Kalani A, Tyaqi N. Homocysteine induced cerebrovascular dysfunction: A link to Alzheimer's disease etiology. Open Neurol J 2015;9:9-14.
Kamat PK, Kyles P, Kalani A, Tyaqi N. Hydrogen sulfide ameliorates homocysteine-induced Alzheimer's disease-like pathology, blood-brain barrier disruption, and synaptic disorder. Mol Neurobiol 2016;53:2451-67.
Williams SR, Yang Q, Chen F, Liu X, Keene KL, Jacques P, et al.
Genome-wide meta-analysis of homocysteine and methionine metabolism identifies five one carbon metabolism loci and a novel association of ALDH1L1 with ischemic stroke. PLoS Genet 2014;10:e1004214.
Huang S, Yin L, Xu Y, Zou C, Chen L. The homocysteine associated variant rs548987 of SLC17A3 confers susceptibility to ischemic stroke in Chinese population. J Neurol Sci 2016;370:78-81.
Zulli A. Endoplasmic stress inhibitors for homocysteine induced cardiovascular disease. Curr Pharm Des 2016;22:2704-8.
Katsiki N, Perez-Martinez P, Mikhailidis DP. Homocysteine and non-cardiac vascular disease. Curr Pharm Des 2017;23:3224-32.
Momin M, Jia J, Fan F, Li J, Dou J, Chen D, et al.
Relationship between plasma homocysteine level and lipid profiles in a community-based Chinese population. Lipids Health Dis 2017;16:54.
Cylwik B, Czygier M, Daniluk M, Chrostek L, Szmitkowski M. Vitamin B12 concentration in the blood of alcoholics. Pol Merkur Lekarski 2010;28:122-5.
Zhou F, Chen B, Chen C, Huang J, Chen S, Guo F, et al.
Elevated homocysteine levels contribute to larger hematoma volume in patients with intracerebral hemorrhage. J Stroke Cerebrovasc Dis 2015;24:784-8.
Dai D, Sun Y, Liu C, Xing H, Wang B, Qin X, et al.
Association of Glasgow coma scale with total homocysteine levels in patients with hemorrhagic stroke. Ann Nutr Metab 2019;75:9-15.
Markišić M, Pavlović AM, Pavlović DM. The impact of homocysteine, Vitamin B12, and Vitamin D levels on functional outcome after first-ever ischaemic stroke. Biomed Res Int 2017;2017:5489057.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]