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. 2021 Jun;6(2):176-184.
doi: 10.1177/23969873211010069. Epub 2021 May 11.

Serum GFAP for stroke diagnosis in regions with limited access to brain imaging (BE FAST India)

Love-Preet Kalra  1 , Himani Khatter  2 , Sarvotham Ramanathan  2 , Sameer Sapehia  2 , Kavita Devi  2 , Abirami Kaliyaperumal  2 , Deepti Bal  2 , Ivy Sebastian  2 , Raviteja Kakarla  2 , Anusha Singhania  2 , Shubhra Rathore  3 , Svenja Klinsing  1 , Jeyaraj Durai Pandian  2 , Christian Foerch  1
Affiliations

Serum GFAP for stroke diagnosis in regions with limited access to brain imaging (BE FAST India)

Love-Preet Kalra et al. Eur Stroke J. 2021 Jun.

Abstract

Introduction: Despite a high burden of stroke, access to rapid brain imaging is limited in many middle- and low-income countries. Previous studies have described the astroglial protein GFAP (glial fibrillary acidic protein) as a biomarker of intracerebral hemorrhage. The aim of this study was to test the diagnostic accuracy of GFAP for ruling out intracranial hemorrhage in a prospective cohort of Indian stroke patients.

Patients and methods: This study was conducted in an Indian tertiary hospital (Christian Medical College, Ludhiana). Patients with symptoms suggestive of acute stroke admitted within 12 h of symptom onset were enrolled. Blood samples were collected at hospital admission. Single Molecule Array technology was used for determining serum GFAP concentrations.

Results: A total number of 155 patients were included (70 intracranial hemorrhage, 75 ischemic stroke, 10 stroke mimics). GFAP serum concentrations were elevated in intracranial hemorrhage patients compared to ischemic stroke patients [median (interquartile range) 2.36 µg/L (0.61-7.16) vs. 0.18 µg/L (0.11-0.38), p < 0.001]. Stroke mimics patients had a median GFAP serum level of 0.14 µg/L (0.09-0.26). GFAP values below the cut-off of 0.33 µg/L (area under the curve 0.871) ruled out intracranial hemorrhage with a negative predictive value of 89.7%, (at a sensitivity for detecting intracranial hemorrhage of 90.0%).

Discussion: The high negative predictive value of a GFAP test system allows ruling out patients with intracranial hemorrhage.

Conclusion: In settings where immediate brain imaging is not available, this would enable to implement secondary prevention (e.g., aspirin) in suspected ischemic stroke patients as soon as possible.

Keywords: GFAP; biomarker; diagnostic method; glial fibrillary acidic protein; intracerebral hemorrhage; intracranial hemorrhage; ischemic stroke.

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Conflict of interest statement

Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Foerch invented the following patent: Use of GFAP for identification of intracerebral hemorrhage (US20150247867). The other authors report no conflicts of interest.

Figures

Figure 1.
Figure 1.
STARD diagram showing flow of patient enrolment.
Figure 2.
Figure 2.
(a) ROC analysis for identifying intracranial hemorrhage. (b) ROC analysis for identifying intracranial hemorrhage in patients with severe neurological deficits (NIHSS > 18).
Figure 3.
Figure 3.
Scatter plot depicting the correlation between intracerebral hemorrhage volume and GFAP serum levels.
See this image and copyright information in PMC

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