REVIEWS
of proinflammatory conditions, suggesting that the association is related to activation of the inflammatory response rather than the c
atory markers that have been associated with stroke risk and prognosis.
mine whether immune system modulators can lower the risk of stroke in individuals with elevated concentrations of inflammatory mark
Acute phase reactants
Serum proteins whose
concentrations increase as a
result of an acute inflammatory
state.
Department of Neurology,
College of Physicians
and Surgeons,
Columbia University,
Neurological Institute,
710 West 168th Street,
New York,
New York 10032, USA.
Correspondence to M.S.E.
mse13@cumc.columbia.edu
doi:10.1038/nrneurol.2016.125
Published online 12 Sep 2016
Understanding the association between the innate
inflammatory response and cardiovascular disease is of
major importance from medical, public health and eco-
nomic perspectives. Cardiovascular disease is the
leading cause of mortality worldwide, accounting for 17.5
million deaths per year; 6.7 million of these deaths are
related to stroke1. Over 80% of strokes are classified as
ischaemic, and approximately two thirds of ischaemic
strokes result from one of three pathological states:
atherosclerosis, lipohyalinosis (a small-vessel disease),
and cardiac embolism with thrombotic material2.
Although each of these states is associated with its
own set of environ- mental, genetic and patient-
specific risk factors, various conditions that acutely
activate the immune system and the subsequent
inflammatory cascade have also been associated with
an increased risk of stroke.
The immune system is made up of two major arms:
the innate system, a highly preserved and nonspecific
group of pathways that detect pathogens and respond
quickly to infection, and the adaptive immune system,
in which lymphocytes provide a targeted immune
response and maintain immunological memory3.
Although each
arm of the immune system makes a different contri-
bution to the pathogenesis of atherosclerotic plaques
and cardiovascular disease, in this Review, we
consider the effects of the immune system as a
whole on the epidemiology of stroke4. We discuss
the associations between specific inflammatory
states, biomarkers of inflammation, and the risk of
incident and recurrent ischaemic stroke. We also
consider the inflammatory mechanisms that might
predispose individuals to the major stroke subtypes.
Finally, we discuss the possibil- ities for prevention
and treatment of ischaemic stroke with approaches
that are intended to limit the body’s inflammatory
response.
Inflammation and risk of stroke
The inflammatory response is mediated by proinflam-
matory prostaglandins, cytokines and chemokines.
These factors attract immune cells, prime the adaptive
immune system, and cause the systemic release of
acute phase reactants. However, some of these
proinflamma- tory proteins — such as IL-6, IL-1β,
tumour necro- sis factor (TNF), complement
proteins, C-reactive
594 | OCTOBER 2016 | VOLUME 12 www.nature.com/nrneurol

.
d

Key points
The risk of ischaemic stroke is associated with systemic inflammation and inflammatory
Acute infections activate the inflammatory cascade, which might increase the subsequenttion riskthat
Chronic infection and infectious burden have been associated with an increased risk of
Various inflammatory mechanisms probably have different roles in different subtypes of stroke
C‑Reactive protein, IL‑6 and lipoprotein‑associated phospholipase A2 are indicators of chronic inflammation and might be biomarkers of stroke risk
Various general and targeted therapeutic strategies that aim to decrease the risk of stroke by reducing inflammation have been studied and remain under investig
protein (CRP), serum amyloid A-1 protein (SAA),
coag- ulation proteins and fibrinogen — act on
endothelial cells, with acute effects that include
induction of throm- bosis, and chronic effects that
might contribute to the formation and maturation of
atherosclerotic plaques. Consequently. inflammation
is likely to have an impor- tant role in the
pathogenesis and progression of athero- sclerosis (FIG.
1), plaque rupture, platelet aggregation and
intravascular thrombosis, all of which increase the risk
of stroke (FIG. 2). Evidence shows that the risk of stroke
is increased by both acute and chronic inflammation.
Acute infection
The association between the acute inflammatory resp-
onse and stroke can be seen in various states of acute
infection. During infection, members of the Toll-like
receptor (TLR) family of transmembrane proteins rec-
ognize conserved ligands — lipopolysaccharide is the
best known example — in pathogens and trigger intra-
cellular transduction processes that lead to expression of
specific genes and production of inflammatory proteins
in host cells; this process is known as the inflammatory
response5,6,7. Pathogen-associated antigens also bind
to pattern recognition receptors, such as TLR4, that
are expressed on immune cells, endothelial cells and
platelets, thereby initiating a cascade of immune
and prothrombotic events that defend the host against
invasion8,9. The complement system is also activated
and helps to clear foreign bodies from tissues10. The
comple- ment system and components of the clotting
cascade are believed to have common evolutionary
origins and still share elements; for example, both are
activated by tissue factor, which is in turn stimulated
by various cytokines, including CRP11,12.
Overexpression of tissue factor acti- vates factor X, a
downstream effector in the coagulation pathway and
an activator of thrombin. Activated fac- tor X and
thrombin induce coagulation and mediate the
inflammatory response by acting on protease-activated
receptors expressed on endothelial cells, platelets and
leukocytes. Other inflammatory cytokines, including
IL-1β, IL-6, and TNF can also activate coagulation
and inhibit fibrinolysis. Besides the direct pathologi-
cal effects of infection and the inflammatory response,
nonspecific complications may also contribute to the
risk of stroke. Such complications include dehydration,
REVIEWS
increased susceptibility to deep vein thrombosis and
secondary paradoxical
biomarkers, suggestingemboli, impaired
a causal cardiac func-
relationship
of stroke
leads to atrial fibrillation, and septic emboli
stroke
from endocarditis.
An association between recent infection and
stroke onset has been suggested by evidence from
recent case-crossover studies. In this type of study,
each individual serves as his own control, thereby
limit- ing confounding factors and enabling the
discovery of time-dependent associations. In one
prospective cohort study of nearly 6,000 elderly
participants, 669 of whom experienced a stroke, the
risk of stroke increased after hospitalization for
infection: odds ratios within 7 days, 14 days and 90
days of hospitalization were 8.0, 7.3 and 2.4,
respectively13. The risk was greatest soon after
infection, and decreased over time (FIG. 3). Similarly,
acute infection increased the risk of stroke at 14 days
(OR 2.11) and 30 days (OR 1.87) in another case-
crossover study of Medicare patients conducted
between 1991 and 2007 (REF. 14). Atrial fibrillation was
shown to account for some, but not all, of the associ-
ation, suggesting that infection itself is followed by
a high-risk prothrombotic period. The risk of stroke
in these studies was not associated with specific
patho- gens: respiratory, genitourinary and skin
infections might all precede ischaemic stroke14,15. A
nested case– control study of recurrent vascular events
after transient ischaemic attack or stroke that
included 711 individu- als failed to identify an
association between infection and an increased risk of
a second vascular event within 6 weeks16. It is thus
possible that recurrent events, as opposed to initial
events, are driven by other risk factors, or that the
power of this sample was insufficient limited to find
an association.
The association between acute infection and inci-
dent stroke is also suggested by more indirect asso-
ciations. For example, increases in proinflammatory
markers after vaccination against Salmonella typhi
were associated with increases in aortic stiffness in a
placebo- controlled study17. This effect was not
observed with sham vaccinations or when aspirin
was administered before vaccination. In another
trial, leukocyte counts were used as a marker of
underlying infection, and increases in leukocyte
count were associated with a short-term increase in
the risk of stroke18.
Overall, these studies suggest a relationship
between acute infection, inflammation and
cerebrovascular events. Nevertheless, further work is
needed to deter- mine the precise nature of the
relationships, and research in this area remains active.
Chronic infection
Chronic infections have been associated with
cardiovas- cular disease and ischaemic stroke, and the
association is thought to be the result of chronic low-
level inflamma- tion. Nevertheless, a causative role for
chronic infection in cardiovascular disease has not yet
been established owing to a lack of evidence from
antibiotic treatment trials. Epidemiological studies
have indicated associ- ations between infection with
various organisms and an increased long-term risk of
stroke; these organisms
NATURE REVIEWS | NEUROLOGY VOLUME 12 | OCTOBER 2016 | 595

.
d
REVIEWS

Pentameric CRP

Lumen Monocyte
LDL
Increased permeability Fibrous cap Platelet activation
Integrin ICAM-1

VCAM-1
Dysregulated collagen and elastin matrix
Monomeric CRP

Endothelium Lp-PLA2 Tissue factor

Metalloproteinases

Intimal plaque Foam cells

Macrophage

Inflammatory cytokines

Internal elastic lamina

Media Smooth muscle cell

Figure 1 | The contribution of inflammation to the development of an atherosclerotic plaque. An initial insult to
the vascular wall causes expression of vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion
molecule 1 (ICAM-1) by endothelial cells, causing monocytes to bind to the endothelium, transmigrate into the vessel
wall and differentiate into macrophages. Macrophages contribute to the inflammatory cascade, leading to the
recruitment of more
macrophages into the vessel wall. Some macrophages also become lipid-laden foam cells, promote smooth muscle
cell proliferation and migration, disorganization of the matrix membrane and further endothelial cell dysfunction.
Ultimately, an atherosclerotic plaque builds owing to the formation of a fibrous cap, disorganized tissue that takes
place of the healthy matrix and consists of muscle cells, macrophages, foam cells, lymphocytes and collagen and elastin
proteins. This process causes luminal stenosis and turbulent blood flow. The final consequences are acute or chronic
vessel injury, loss of endothelial homeostasis and platelet activation by tissue factor, which may be partly mediated by
C-reactive protein
(CRP). LDL, low-density lipoprotein; Lp-PLA2, lipoprotein-associated phospholipase A2. Modified with permission from
Nature Publishing Group © Charo, I. F. C Taub, R. Nat. Rev. Drug Disc. 10, 365–376 (2011).

include Chlamydia pneumoniae, Helicobacter pylori,

a moderate association between a weighted infectious
Mycoplasma pneumoniae, Haemophilus influenzae,
burden score and the risk of stroke22. The NOMAS
herpes simplex virus (HSV) 1 and 2, human cytomeg-
investigators analysed serological profiles against
alovirus (CMV), influenza virus, and Epstein–Barr
C. pneumoniae, H. pylori, CMV, HSV1 and HSV2 in
virus19–21. Evidence suggests that cumulative exposure
~1,600 individuals who were stroke-free at the time
to multiple infections — a high ‘infectious burden’ —
of enrolment and followed up for a median of 8
has an additive effect on the risk of vascular disease 22.
years; 56 patients experienced an ischaemic stroke
Infectious burden can be calculated as the weighted
during the follow-up period. Cox proportional
sum of serological profiles (IgG, IgM or IgA) against
hazards mod- els were used to determine
several pathogens to produce an aggregated score. The
associations between dif- ferent serological profiles
exact definition varies between studies, but the concept
and the risk of stroke, and a weighted index of
that infectious burden might be a more robust predictor
infectious burden was developed. After adjusting for
of incident cardiovascular disease than any individual
known risk factors and inflamma- tory biomarkers,
infection is gaining epidemiological support23.
such as CRP and leukocyte count, a high infectious
Studies in which infectious burden has been meas-
burden was associated with an increased risk of stroke
ured have found an association of higher infectious
(HR 1.39 per standard deviation in infec- tious burden
burden with an increased risk of coronary artery dis-
score), as well as increased carotid plaque thickness,
ease, myocardial infarction, and cardiovascular death24,
irregular plaque morphology and cogni- tive
and data are now emerging in relation to stroke. The
impairment22,25. Similarly, a prospective popula-
Northern Manhattan Study (NOMAS), a prospective
tion-based survey designed to study the
cohort study of stroke and stroke risk factors, revealed
pathogenesis of atherosclerosis over a 5-year period
revealed a signif- icant association of respiratory,
 urinary and other types

596 | OCTOBER 2016 | VOLUME 12 www.nature.com/nrneurol

.
d

Arterial dolichoectasia
Pathological dilation and
elongation of arteries through
chronic vessel wall remodelling.
Acute infection Inflammatory cascade activation
Inflammatory markers
Multiple chronic infections Chronic inflammation
Genetic, host-specific and environmental factors
Figure 2 | The proposed role of infection and inflammation in acute ischaemic stroke. Both acute and chronic
infection leads to inflammation that contributes to thrombogenesis, atherosclerosis and platelet activation, all of which
increase the risk of stroke. Genetic, host-specific and environmental factors may modify an individual’s susceptibility to
the effects of inflammation.
of chronic infection with an increased risk of athero-
sclerosis26. Other chronic inflammatory conditions with
multiple infectious aetiologies, such as periodontitis and
bronchitis, have also been associated with an increased
risk of stroke27–29.
Other studies have failed to provide consistent evi-
dence for an association between infectious burden
and the risk of stroke. No association was found in the
Framingham Heart Study30, which looked at incident
cardiovascular disease as a whole, and no association
was found with ischemic stroke in the Heart Outcomes
Prevention Evaluation (HOPE), although this study
did find an association between infectious burden
and a combined outcome of cardiovascular disease 24.
Inconsistencies between studies might be related to
differences between cohorts and the complex interplay
between serological markers, stress, access to health-
care, and psychosocial status, all of which additionally
affect infectious burden, risk of stroke and levels of
inflammation31. In addition, most studies have been
limited by a small sample size and selection for lim-
ited pathogens. For these reasons, the relationship
between infectious burden and stroke risk remains
under investigation.
The concept of infectious burden as a risk factor
for stroke implies a cumulative effect of many differ-
ent infections through common effects on the inflam-
matory and coagulation cascades, but some infections
can have a more direct and specific effect on risk
through their invasion of blood vessels. For example,
the endotheliotropic varicella-zoster virus has been
identified as a direct cause of arterial inflammation
and vascular injury in some patients with stroke 32.
Recently, the human immunodeficiency virus (HIV)
has also been associated with premature, accelerated
atherosclerosis and an increased risk of acute
ischaemic events33,34. Moreover, pathological studies
have revealed that HIV-positive patients manifest both
extremes of cerebral arterial remodelling: inward
remodelling and atherosclerosis that result in a
thicker arterial wall, and outward remodelling that
involves vessel dilata- tion, thinning of the tunica
media and, ultimately, arte- rial dolichoectasia35. Whether
the vascular effects of HIV infection are the result of
local inflammation or chronic antiretroviral therapy,
however, remains unclear.
REVIEWS
Thrombogenesis
Platelet activation
Acute ischaemic stroke
Atherosclerosis
Inflammatory biomarkers and stroke
Besides proinflammatory conditions that result from
spe- cific infections, low-grade chronic inflammation has
been associated with an increased burden of
atherosclerotic disease and an elevated risk of
ischaemic stroke36–38. Such chronic inflammation is
indicated by the presence of biomarkers, including
CRP, IL-6, lipoprotein-associated phospholipase A2
(Lp-PLA2, also known as platelet- activating factor
acetylhydrolase), SSA and intercellular adhesion
molecule 1 (ICAM-1). Some of these mark- ers have
been assessed for their value as biomarkers to predict
an individual’s risk of ischaemic stroke.
C-reactive protein and IL-6
Several large epidemiological studies have consist-
ently found higher circulating levels of CRP using a
high-sensitivity assay (commonly referred to as high-
sensitivity CRP, or hsCRP) to be associated with an
increased risk of vascular events independent of tra-
ditional vascular risk factors 39. For example, in the
Women’s Health Study, in which several inflamma-
tory markers were tested, hsCRP was the only inflam-
matory marker to independently predict cardiovascular
risk40, and the inclusion of hsCRP levels in a model to
predict cardiovascular disease improved the predictive
value of the model39. CRP has become the inflamma-
tory marker of choice in the clinical setting because of
this consistent association with cardiovascular events,
its long half-life, and stability when stored frozen for
prolonged periods of time.
Properties of CRP. CRP is a liver-synthesized blood
constituent that is rapidly released in response to infec-
tion, tissue damage or nonspecific immune system
activation. Production of CRP in the liver is mainly
regulated by IL-6. CRP is a member of the pentraxin
family of immune response proteins, and can exist in
monomeric or pentameric forms; pentameric CRP is
the predominant form produced in the liver and found
in the serum, whereas monomeric CRP exists in local
tissues, such as the vascular wall, where the pentamer
dissociates41. Dissociation of pentameric CRP into
inter- mediate and monomeric forms also happens at
sites of inflammation, and is facilitated by
phosphatidylcholine in cell membranes42. Monomeric
CRP is thought to have
NATURE REVIEWS | NEUROLOGY VOLUME 12 | OCTOBER 2016 | 597

.
d
REVIEWS

Lacunar strokes
Occlusions of a deep
penetrating artery leading to
infarction of a relatively small
cerebral territory.
Relative risk of stroke
atherogenic and thrombogenic properties, as it
interacts with other immune mediators to activate
platelets and complement proteins43. Functionally,
each CRP mono- meric subunit has a recognition
face and an effector face 44,45. The recognition face
can bind to a diverse set of structural groups,
including phosphocholine resi- dues in the C-
polysaccharide fraction of Streptococcus pneumoniae
and apoptotic cells, nuclear autoantigens, and
lipoproteins44. Binding of the recognition face
induces a conformational change that allows the effec-
tor face to activate the complement pathway by
binding to C1q and Fc receptors, some of which are
found on endothelial cells46,47.
Association with incident stroke. In the past 20 years,
the relationship between hsCRP levels and
cardiovascu- lar disease, including stroke, has been
investigated exten- sively in epidemiological studies
(TABLE 1). Combined evidence suggests that people
with hsCRP levels in the highest quartile are 2–7-fold
more likely to develop acute coronary syndrome,
stroke and peripheral artery disease than are people
with hsCRP levels in the lowest quartile48. This effect
is independent of traditional vas- cular risk factors, but
a synergistic effect seems to occur when high levels of
CRP are combined with high levels of cholesterol48. A
meta-analysis of 54 prospective cohort studies,
including a total of >160,309 individuals, found a
modest association between CRP levels and cardio-
vascular disease, including ischaemic stroke (risk ratio
1.27 (95% CI 1.15–1.40) per standard deviation
increase in the log of CRP concentration)49. Similar
results were obtained in a meta-analysis of 12
observational studies of CRP and stroke risk50.
In the Honolulu Heart Program study, the associ-
ation between high hsCRP levels and an increased risk
of stroke was found to be strongest in patients aged
<55 years who have no history of hypertension or
dia- betes51. This evidence has led to the hypothesis
that the association between hsCRP and stroke is
strongest at younger ages, after which traditional risk
factors become stronger drivers of ischaemic stroke.
The hypothesis that the effect of inflammation on
the risk of stroke is smaller in older people and people
with other risk factors
is indirectly supported by observations from
NOMAS52, in which the patient cohort included a
disproportion- ate number of elderly individuals and
individuals with a high burden of comorbid vascular
conditions (par- ticularly diabetes). In this population,
hsCRP predicted the risk of heart disease and death
after adjusting for other vascular risk factors, but did
not predict the risk of stroke. Moreover, the relative
levels of hsCRP and IL-6 seemed to be more
important than the absolute levels of the markers in
predicting the risk of stroke in this study: individuals
with high levels of IL-6 relative to their levels of hsCRP
(IL-6 dominant individuals) had a lower risk of
ischaemic stroke (RR 0.6) than people with levels of
CRP and IL-6 in the same quartiles, whereas individ-
uals with relatively high hsCRP levels (CRP-dominant)
had a higher risk of ischaemic stroke (RR 2.6). This
find- ing suggests differential effects of inflammation
related to healthy ageing (IL-6-dominant
inflammation) and pathological, premature
inflammation (CRP-dominant), but the results have
not been replicated in other studies and further
investigation is needed53.
As in NOMAS, patients enrolled into the Rotterdam
Study were aged ≥55 years, and the findings were
similar: increasing levels of hsCRP were only mildly
associated with an increased risk of stroke 54.
Subcortical white matter disease was associated with
hsCRP levels, but no association was found between
hsCRP levels and the development of lacunar strokes.
In contrast to the Women’s Health Study, addition of
hsCRP levels to pre- dictive models in the Rotterdam
study did not improve individual stroke risk
prediction55.
Variation between studies in the observed associ-
ations between hsCRP levels and the risk of incident
stroke has been attributed to differences in patient
demographics, prevalences of comorbid conditions,
and the extents to which comorbidities have been
accounted for in the study design and statistical
analysis. Overall, despite the fact that multiple studies
have shown a robust relationship between hsCRP levels
and incident stroke, the value of using hsCRP levels in
the clinical setting, specifically as an additive to other
stroke prediction models, remains unclear.
Genetic studies have also indicated an association
between CRP and the risk of ischaemic stroke. One
study has indicated that single nucleotide
polymorphisms in the CRP gene are associated with
minor elevations in hsCRP levels, and that some of
these polymorphisms are also associated with a 25%
increase in the risk of ischae- mic stroke56. A genome-

?
Active infection
Weeks
Figure 3 | Association between acute infection and stroke risk. Evidence suggests
that the risk of stroke is increased immediately after acute respiratory, urinary or
skin infection and progressively decreases in the weeks to months thereafter. The
effect on risk of stroke during infection is unknown.
wide association study from the Women’s Health
Study suggested that several genes associated with
weight homeostasis, insulin resistance and premature
atherothrombosis (that is, the metabolic syndrome) are
also associated with elevated plasma con- centrations of
CRP57. Furthermore, certain haplotypes of the CRP and
IL6 genes have been associated with MRI- defined
small vessel ischaemic strokes in adults aged
≥65 years58.
Association of CRP and other inflammatory markers
with recurrent stroke. Data on the role of CRP in
pre- dicting stroke recurrence are more limited than those

598 | OCTOBER 2016 | VOLUME 12 www.nature.com/nrneurol

.
d
 REVIEWS

Table 1 | Patient characteristics and s from prospective studies that have CRP with stroke
result cohort linked
Study Study demographics Association of
hsCRP levels
Mean age Patients Patients Current
with stroke
(years) with DM (%) with HTN smokers
risk (95% CI)*
(%) (%)
Risk of first-time stroke (primary stroke)
The Physicians Heart Study38 62 12 35 18 RR 1.9 (1.1–3.3)
The Cardiovascular Health Study87 73 15 (22)‡ 42 (58)‡ 12 RR 1.6 (1.2–2.1)
Honolulu Heart Program51 56 (58)‡ 13 (27)‡ 11 (27)‡ 38 (54)‡ OR 1.6 (1.1–2.4)
Northern Manhattan Study (NOMAS)
52
69 22 21 17 HR 1.2 (0.8–1.9)
(Type 2 DM)
Rotterdam Study55 68 11 18 23 HR 1.1 (95%
(Type 2 DM) CI 1.0 - 1.2)
Risk of stroke recurrence (secondary stroke)
Perindopril Protection Against60Recurrent 66 11 (18) 43 (58)‡ 17 (23)‡ RR 1.4 (1.1–1.9)
Stroke Study (PROGRESS) (Type 2 DM)
Levels of Inflammatory Markers in the 63 37 75 21 HR 2.3 (1.2–4.7)
62
Treatment of Stroke (LIMITS) (Type 2 DM)
Northern Manhattan Stroke Study 69 32 68 23 HR 0.7 (0.4–1.4)
59
(NOMASS) (Type 2 DM)
*The comparison made in all studies was the risk of stroke among patients with hsCRP levels in the highest quartile versus the risk of
stroke among patients with hsCRP levels in the lowest quartile. ‡First number is the proportion of patients without the outcome
of stroke, the number in brackets is the proportion of patients with the outcome of stroke. CRP, C-reactive protein; DM, diabetes
mellitus; HTN, hypertension; RR, relative risk; OR, odds ratio; HR, hazard ratio.

on its role in predicting incident stroke. In a study

mediates atherogenesis related to classical risk factors
that included only stroke survivors, hsCRP levels
such as ageing, hypertension, smoking and obesity 63.
measured shortly after a first ischaemic stroke were
This hypothesis is supported by Mendelian randomization
associated with increased mortality, but not with
studies: a large meta-analysis of 47 studies of CRP pol-
recurrent stroke, dur- ing 4 years of follow-up59.
ymorphisms failed to find a causal association between
However, other studies have suggested an association.
CRP levels and coronary heart disease, whereas a
In a nested case–control study of 472 patients with
similar meta-analysis of IL6 polymorphisms and the
ischaemic stroke, the third of partici- pants with the
effect of IL-6-related pathways on cardiovascular
highest levels of CRP had an increased risk of stroke
events found evidence for a modest causal role of IL-6
recurrence (RR 1.39)60. The same study found similar
levels in the development of coronary heart
associations of other inflammatory markers,
disease64,65,66.
including fibrinogen, IL-6 and TNF, with stroke
Studies of the association between IL-6 levels and
recur- rence61. Similarly, the Levels of Inflammatory
stroke as a primary outcome are rare, but findings of
Markers in the Treatment of Stroke (LIMITS) study
those conducted to date are consistent with the results
showed that CRP levels could be used to predict the
of coronary heart disease studies that show a linear
risk of recur- rent stroke in patients with recent
association between IL-6 levels and cardiovascular
lacunar stroke62. In this study, CRP levels were
events48,67,68. Nevertheless, determining whether IL-6 is
measured in the subacute phase after lacunar stroke,
both a biomarker and mediator of pathogenic pathways
and individuals with CRP levels in the highest
is critical for the development of novel therapeutic tar-
quartile were found to have double the risk of stroke
gets, and multiple clinical trials are currently assessing
recurrence than those with CRP levels in the lowest
the effects of targeted cytokine antagonist therapies on
quartiles (HR 2.3), even after adjustments for
cardiovascular events69,70.
demographics and vascular risk factors. Differences in
the ability of CRP levels to predict first-time stroke
Lipoprotein-associated phospholipase A2
and recurrent stroke might be the result of
Lp-PLA2 is a leukocyte-derived enzyme that is
differences between chronic low-level inflammation
released in response to inflammation and is thought
and acute or subacute inflammation in the post-
to directly propagate atherogenesis by hydrolysing
stroke period.
low-density lipoprotein (LDL) to form oxidized
phospholipids with direct inflammatory properties
IL-6 as a biomarker of stroke risk. Despite the uncer-
and proinflammatory downstream signalling effects.
tainties left by the evidence discussed above, there seems
Lp-PLA2 has also been
to be a consistent association between hsCRP levels and
Mendelian randomization vascular events, including stroke. For that reason, suggest that this cytokine
The random assortment of
the current prevailing hypothesis is that CRP is a
genetic alleles in a person or a
population that can be used
biomarker for inflammation-related atherogenesis
as a method to study the risk and/or throm- bosis. IL-6 is the main driver of CRP
of having that allele. production in the liver, and the available data
shown to accumulate endothelial cells, smooth muscle cells and measured, although these two parameters do correlate
in atherosclerotic monocytes. Importantly, outcomes differ when with each other71.
lesions and affect functional activity or levels of Lp-PLA2 are

NATURE REVIEWS | NEUROLOGY VOLUME 12 | OCTOBER 2016 | 599

.
d
REVIEWS

An association between Lp-PLA2 levels and the

associations come from studies that have looked at the
risk of stroke was first demonstrated in the
relationship between markers of systemic inflamma-
Rotterdam Study: the risk of stroke in individuals
tion and carotid plaque growth, plaque instability
with Lp-PLA2 levels in the highest quartile was
and plaque rupture81,82.
nearly double that of individuals with levels in the
lowest quartile72. In NOMAS, Lp-PLA2 levels were
Large artery atherosclerosis
associated with the risk of atherosclerotic stroke in
Symptomatic carotid artery stenosis accounts for about
non-Hispanic white people, but not in other ethnic
15–30% of all ischaemic strokes83,84, and stroke recur-
groups73. In a study that meas- ured Lp-PLA2 activity
rence is extremely common in patients with severe
in patients with stroke, Lp-PLA2 activity in the
atherosclerotic stenosis of the carotid artery85,86.
highest quartile was associated with a 2.5-fold
Several lines of evidence indicate that high levels of
increase in the risk of stroke recurrence relative to
hsCRP are associated with carotid atherosclerosis and
activity in the lowest quartile59.
risk of stroke. In one study of 1,269 individuals with
The Atherosclerosis Risk in Community (ARIC)
asymptomatic carotid atherosclerosis, progression of
study, which included nearly 13,000 individuals aged
atherosclerosis was associated with increasing levels of
45–64 years and who were healthy when enrolled,
hsCRP39. In another prospective study of over 5,400
simultaneously assessed the value of LDL, CRP and
individuals, lev- els of hsCRP were associated with the
Lp-PLA2 in predicting the risk of stroke. LDL levels
risk of stroke inde- pendently of carotid atherosclerosis,
were similar in patients who had a stroke and controls
but higher levels of carotid artery disease increased the
who did not, but levels of Lp-PLA2 in the highest
effect, suggesting an additive effect87. A pathological
quar- tile were associated with a twofold increase in
study of endarterec- tomy samples from 62 patients
stroke over 6–8 years after adjusting for typical risk
showed an association between the number of
factors, cholesterol levels, and CRP levels 74. High
lymphocytes in the atheroma and high serum levels of
levels of Lp-PLA2 and high blood pressure exhibited
hsCRP, plaque ulceration or recent intra-plaque
a syner- gistic effect on the risk of stroke, and people
haemorrhage88.
with levels of both Lp-PLA2 and CRP in the top
The role of systemic inflammation in plaque insta-
quartile had an 11-fold increase in the risk of stroke
bility is probably small when compared with the
compared with those with both levels in the bottom
effects of traditional risk factors such as hypertension,
quartile. These results suggest that high Lp-PLA2 and
hypercholesterolaemia and low levels of high-density
CRP levels are associated with the risk of stroke
lipoprotein89,90. Nonetheless, a role for inflammation
independent of tradi- tional vascular risk factors and
in atherosclerotic plaque growth and plaque instabil-
each other, but can iden- tify individuals at particularly
ity in the extracranial circulation is indicated by the
high risk of stroke when combined 75. A meta-analysis
observation that specific single nucleotide polymor-
that included the studies mentioned and other cohort
phisms in inflammatory genes have associations with
studies revealed a mild but significant association of
symptomatic carotid disease91. In addition to extra-
levels and activity of Lp-PLA2 with the incidence of
cranial carotid artery atherosclerosis, intracranial large
ischaemic stroke.
artery atherosclerosis is becoming recognized as one of
On the basis of current evidence, whether and how
the most common causes of ischaemic stroke
the measurement of Lp-PLA2 levels or functional
worldwide, especially in Asia, where up to 50% of
activity can contribute to risk stratification and clini-
strokes have been attributed to intracranial stenosis92,93.
cal management beyond the information gained from
Levels of circulat- ing inflammatory markers have
LDL levels remains unclear. In one study, for example,
been associated with such intracranial atherosclerosis
changes in levels and functional activity of Lp-PLA2
in much the same way as they have been associated
did not correlate with a reduction of cardiovascular
with plaque growth in the extracranial carotid artery 94.
events with statin therapy76,77. In addition, bioactive
Lp-PLA2 circulates in complex with apolipoprotein B,
Small vessel infarcts
and statistically adjusting for levels of LDL in
Data on the association between inflammatory mark-
epidemio- logical studies of risk mitigates much of the
ers and small vessel infarction are limited. One study
associa- tion between Lp-PLA2 and cardiovascular
found levels of IL-6, but not hsCRP, to be associated
outcomes, further bringing into question its clinical
with silent, first-time small vessel infarcts, and other
utility as a biomarker77. Whether Lp-PLA2 could be a
studies have indicated an association between both IL-
therapeu- tic target is equally as unclear: two large
6 and CRP and small-vessel disease95,96. In the LIMITS
randomized placebo-controlled trials of darapladib, a
study, patients with hsCRP concentrations in the sub-
novel inhibitor of Lp-PLA2, have been conducted, but
acute phase after lacunar stroke that were in the highest
they failed to show that the drug prevents
quartile had double (HR 2.3) the risk of stroke recur-
cardiovascular outcomes, including ischaemic
rence than those with hsCRP levels in the lowest quar-
stroke78,79,80.
tile, even after adjusting for demographics and
vascular risk factors62. In addition, imaging studies
Inflammation and stroke subtypes
have indi- cated an association between levels of IL-6,
Different inflammatory mechanisms are likely to
CRP and other inflammatory biomarkers, and the
influence the risk of different stroke subtypes in dif-
progression of small-vessel white matter disease, an
ferent ways. In this section, we discuss what is
entity that shares many risk factors with small-vessel
known about the inflammatory mechanisms that
stroke54,97–100.
contrib- ute to different stroke subtypes. Most data
on such
600 | OCTOBER 2016 | VOLUME 12 www.nature.com/nrneurol

.
d

Cardioembolic stroke
High levels of circulating inflammatory markers were
previously thought to be caused by atrial fibrillation,
but a growing body of evidence now suggests that
inflam- mation predicts the development of atrial
fibrillation and subsequent thromboembolism101,102,61.
Therefore, inflammatory mechanisms are now thought
to result from, contribute to, and modify the
prothrombotic state associated with atrial fibrillation103–
105
. Further research is needed to determine the clinical
significance and thera- peutic implications of
inflammation as a risk factor for stroke among patients
with atrial fibrillation, as well as in patients with occult
atrial dysfunction (also called atrial cardiopathy) that
has not yet manifested as atrial fibril- lation but might
still be associated with an elevated risk of stroke106,107.
Prevention and treatment of inflammation
Primordial prevention methods
With 35% of the US population now considered to
be obese, primordial stroke prevention with a focus
on improving community-wide healthcare practices
is important. Diet and exercise have been shown to
mod- ulate major risk factors for stroke, and this
observation holds true for inflammation108. There are
no rand- omized controlled trials measuring the effect
of exercise on inflammation and risk of stroke, but
observational studies have demonstrated that physical
activity is asso- ciated with a reduced risk of
stroke109,110. Moreover, prospective studies have
shown that weight loss inter- ventions lead to
reductions in serum concentrations of CRP, IL-6, and
TNF. Similarly, a Mediterranean diet that is rich in
polyunsaturated fatty acids, fruits, vegetables and
whole grains, and includes a moderate intake of
alcohol and a low intake of processed and red meat has
been associated with low levels of inflammation 111–113.
The PREDIMED trial, a randomized controlled trial
that compared the Mediterranean diet with a standard
low- fat diet, showed that following a Mediterranean
diet for nearly 5 years decreased the risk of
cardiovascular events and, more specifically, stroke114,115.
By contrast, a Western diet that is rich in red meat,
simple carbohydrates, high-fat dairy products and
hydrogenated fats has been associated with increased
levels of inflammatory markers, including CRP and
IL-6 (REFS 113,116).
Vaccinations and antibiotics
Observational studies suggest that the risk of stroke is
increased in the 2–4 weeks after acute infection with
flu- like illnesses13. An observational study of nearly
300,000 people found that receipt of an annual
influenza vaccine was associated with a reduction of
~20% in the rate of hospitalization for cerebrovascular
disease117. Similarly, a Cochrane review of eight
randomized controlled trials with a total of 12,029
participants showed that influenza vaccination
decreased the number of cardiovascular out- comes, and
a case series study that used a within-person method of
comparison found that the risk of stroke was increased
after respiratory tract infection but remained stable
after vaccination against influenza, pneumo- coccal
infection and tetanus118,119. On the basis of this
REVIEWS
evidence, annual vaccination against influenza might,
therefore, affect stroke rates and should be received by
individuals who are at moderate to high risk of stroke,
as emphasized in recent guidelines 120–124. However, not
all vaccinations studied have been shown to decrease
the risk of stroke. Among a cohort of men aged ≥45
years, the pneumococcal vaccine was not associated
with a reduced risk of stroke123.
In light of the evidence that certain infections are
associated with the risk of vascular disease, antibiotics
have been tested as a way to prevent cardiovascular
events. However, in clinical trials of antichlamydial
antibiotic therapy, for example, active treatment did
not have any benefit on the risk of cardiovascular dis-
ease125,126. A meta-analysis from 2005 combined results
from 11 studies, including a total of 19,217 partici-
pants, who were treated with antibiotics, and did not
find any benefit of anti-chlamydial therapy in reducing
cardiovascular events or all-cause mortality127.
Primary and secondary prevention
Statins. Statins are probably the most studied class of
anti-inflammatory drugs in the context of atheroscle-
rotic and cardiovascular disease. Beyond the primary
effect of statins — lowering levels of LDL by
inhibiting the downstream cholesterol products of the
mevalonate pathway these drugs might also improve
endothelial function and attenuate inflammation.
Evidence that stat- ins reduce the risk of stroke comes
from a trial in which healthy individuals with normal
LDL levels and mildly elevated hsCRP levels received
high-dose rosuvastatin or a placebo. After a 2-year
follow up period, the rate of stroke was 48% lower in
the treatment group than in the placebo group (absolute
risk reduction of 0.16%)128. This value equates to a
yearly number needed to treat of over 500 to prevent
one stroke, but the additional reduction in risk of other
cardiovascular outcomes could provide a rationale for
the use of rosuvastatin in patients with ele- vated
hsCRP levels. Furthermore, the absolute reduction in
risk was greatest among those with the highest levels
of hsCRP, reflecting the fact that these patients were at
higher risk of cardiovascular events overall.
Overall, these results support the use of statins
for the primary and secondary prevention of stroke,
especially for individuals at moderate to high risk. The
effects of statins are thought to be both lipid-dependent
and anti-inflammatory, and evidence is building that
the anti-inflammatory effects result from their abil-
ity to interrupt isoprenoid biosynthesis and improve
endothelial function, thereby lowering levels of
CRP, IL-1, IL-6 and other inflammatory markers129.
Evidence also indicates that statins inhibit the
expression of adhe- sion molecules such as vascular
cell adhesion molecule 1 (VCAM-1), ICAM-1 and E-
selectin, thereby reducing adhesion and recruitment
of inflammatory cells to atherosclerotic plaques130–
132
.
TNF and cytokine inhibition. Anti-TNF agents, such
as adalimumab, infliximab and etanercept, are now
being considered for the prevention of cardiovascular
disease133. TNF has been shown to alter endothelial and
NATURE REVIEWS | NEUROLOGY VOLUME 12 | OCTOBER 2016 | 601

.
d
REVIEWS

smooth muscle cell function, leading to progression

immune system are shared with the coagulation sys-
of atherosclerosis134. Interest in the possibility of TNF
tem, with the potential to induce a hypercoagulable
inhibition for prevention of cardiovascular disease
state whenever the system is acutely activated. When
increased when observational studies identified that the
chronically activated, such as during chronic
incidence of cardiovascular events among patients who
subclinical infection, the inflammatory system can
were being treated for autoimmune conditions (such
cause vascular dysfunction, resulting in premature
as rheumatoid arthritis and psoriasis) with these drugs
atherosclerosis and vessel thrombosis. The relationship
was lower than among patients receiving other
between the inflam- matory response system and acute
standard therapies69. Prospective trials of anti-TNF
ischaemic stroke has been explored in the context of
agents for the prevention of cardiovascular disease
acute and chronic infection with various pathogens.
have consequently been proposed.
Although most stud- ies have been retrospective,
The same protective effect has been seen with other
results have consistently shown an association between
agents, including methotrexate, which has been shown
the incidence of stroke and recent onset of acute
to reduce levels of TNF, IL-6 and CRP70. The ability of
infection, chronic infection (defined by an aggregate
methotrexate to reduce the risk of secondary major
score called infectious bur- den), or chronic low-level
cardiovascular events will be tested in the
activation of the inflamma- tory system. When
Cardiovascular Inflammation Reduction Trial135.
considered outside the context of a specific disease,
Targeted inhibition of other cytokines, including inflammation as defined by abnormally high levels of
IL-1 and IL-6, is also under investigation. For inflammatory markers, such as CRP, IL-6, Lp-PLA2,
example, inhibition of IL-1 with canakinumab will SAA and ICAM-1, has been associated with an
be tested in the Canakinumab Anti-Inflammatory increased risk of stroke. Of these markers, CRP is the
Thrombosis Outcomes Study to determine whether best characterized.
the inhibition reduces recurrence of myocardial
Much like the management of stroke risk from
infarction, stroke and cardiovascular death among
classic risk factors, the risk from inflammation can
patients with persistently high levels of CRP despite
be reduced with basic preventive methods. Evidence
the use of current second- ary prevention
suggests that a healthy diet — particularly the Medi-
strategies136. Other drugs that mediate inflammation
terranean diet — reduces the risk of incident stroke.
and have the potential to be used in the prevention
Evidence for synergistic effects between inflammation
of cardiovascular disease are peroxisome
and classic stroke risk factors mean that clinicians
proliferator-activated receptor (PPAR) modulators,
should continue to strive for optimal reduction of
AMP-activated protein kinase activators, and C–C motif
blood pressure and lipid levels. In patients with a mod-
chemokine receptor 2 antagonists137–141. Further
erate to high risk of cardiovascular disease, vaccination
study of all these potential therapies is necessary
against influenza is a more specific measure that can
before any clinical recommendations can be
be implemented. Immunotherapy with methotrexate
made142.
and anti-TNF agents is currently being studied in
cardio- vascular disease, as are novel antagonists of IL-
Conclusions 1 and IL-6. These approaches could provide the next
The innate immune system can quickly identify patho- gener- ation of measures to reduce the incidence of
gens and rapidly initiate an inflammatory response stroke in certain patient populations.
to halt infection. However, some targets of the
innate

9. Russell, J. A. Management of sepsis. N.

Engl. J. Med. 355, 1699–1713 (2006).
1. Mendis, S., Davis, S. & Norrving, B. Organizational 10. Wang, R., Xiao, H., Guo, R., Li, Y. & Shen, B. The role
update: the world health organization global of C5a in acute lung injury induced by highly pathogenic
status report on noncommunicable diseases 2014; viral infections. Emerg. Microbes Infect. 4, e28 (2015).
one more landmark step in the combat against 11. Cermak, J. et al. C-reactive protein induces human
stroke and vascular disease. Stroke 46, e121– peripheral blood monocytes to synthesize tissue factor.
122 (2015). Blood 82, 513–520 (1993).
2. Adams, H. P. Jr et al. Classification of subtype of 12. Wu, J. et al. C-reactive protein enhances tissue factor
acute ischemic stroke. Definitions for use in a expression by vascular smooth muscle cells:
multicenter clinical trial. TOAST. Trial of Org 10172 mechanisms and in vivo significance. Arterioscler.
in Acute Stroke Treatment. Stroke 24, 35–41 Thromb. Vasc. Biol. 28, 698–704 (2008).
(1993). 13. Elkind, M. S. et al. Hospitalization for infection and risk
3. Litman, G. W., Rast, J. P. & Fugmann, S. D. The of acute ischemic stroke: the Cardiovascular Health
origins of vertebrate adaptive immunity. Nat. Rev. Study. Stroke 42, 1851–1856 (2011).
Immunol. 10, 543–553 (2010). This article provides evidence that acute infection is
4. Hansson, G. K. & Berne, G. P. Atherosclerosis and associated with a subsequent period of increased
the immune system. Acta Paediatr. Suppl. 93, stroke risk.
63–69 (2004). 14. Levine, D. A., Langa, K. M. & Rogers, M. A. Acute
5. Opal, S. M. & Esmon, C. T. Bench-to-bedside infection contributes to racial disparities in stroke
review: functional relationships between mortality. Neurology 82, 914–921 (2014).
coagulation and the innate immune response and 15. Paganini-Hill, A. et al. Infection and risk of ischemic
their respective roles in the pathogenesis of sepsis. stroke: differences among stroke subtypes. Stroke 34,
Crit. Care 7, 23–38 (2003). 452–457 (2003).
6. Delvaeye, M. & Conway, E. M. Coagulation and innate This study suggests that acute respiratory
immune responses: can we view them separately? infections lead to higher risk of stroke from large
Blood 114, 2367–2374 (2009). vessel atherosclerosis and cardioembolism.
7. Ross, R. Atherosclerosis — an inflammatory disease. 16. Selvarajah, J. R. et al. Does inflammation predispose
N. Engl. J. Med. 340, 115–126 (1999). to recurrent vascular events after recent transient
An overview of the inflammatory mechanisms ischaemic attack and minor stroke? The north-west of
underlying atherogenesis. England transient ischaemic attack and minor stroke
8. Antoniak, S. & Mackman, N. Multiple roles of (NORTHSTAR) Study. Int. J. Stroke 6, 187–194
the coagulation protease cascade during virus (2011).
infection. Blood 123, 2605–2613 (2014).

17. Vlachopoulos, C. et al. Acute systemic
inflammation increases arterial stiffness and
decreases wave reflections in healthy
individuals. Circulation 112, 2193–2200
(2005).
18. Grau, A. J. et al. Leukocyte count as an
independent predictor of recurrent ischemic
events. Stroke 35, 1147–1152 (2004).
19. Espinola-Klein, C. et al. Are morphological or
functional changes in the carotid artery wall
602 | OCTOBER 2016 | VOLUME 12
.
d
associated with Chlamydia pneumoniae.
Helicobacter pylori, cytomegalovirus, or herpes
simplex virus infection? Stroke 31, 2127–2133
(2000).
20. Sorlie, P. D. et al. A prospective study of
cytomegalovirus, herpes simplex virus 1, and
coronary heart disease: the Atherosclerosis Risk in
Communities (ARIC) Study. Arch. Intern. Med.
160, 2027–2032 (2000).
21. Kalayoglu, M. V., Libby, P. & Byrne, G. I.
Chlamydia pneumoniae as an emerging risk
factor in cardiovascular disease. JAMA 288,
2724–2731 (2002).
22. Elkind, M. S. et al. Infectious burden and risk of
stroke: the Northern Manhattan Study. Arch. Neurol.
67, 33–38 (2010).
23. Elkind, M. S. Infectious burden: a new risk factor and
treatment target for atherosclerosis. Infect.
Disord. Drug Targets 10, 84–90 (2010).
24. Smieja, M. et al. Multiple infections and subsequent
cardiovascular events in the Heart Outcomes
Prevention Evaluation (HOPE) Study. Circulation 107,
251–257 (2003).
www.nature.com/nrneurol

25. Katan, M. et al. Infectious burden and cognitive
function: the Northern Manhattan Study. Neurology
80, 1209–1215 (2013).
26. Kiechl, S. et al. Chronic infections and the risk of
carotid atherosclerosis: prospective results from a
large population study. Circulation 103, 1064–1070
(2001).
27. Palm, F. et al. Biomarkers of periodontitis and
inflammation in ischemic stroke: a case-control study.
Innate Immun. 20, 511–518 (2014).
28. Grau, A. J. et al. Association of symptoms of
chronic bronchitis and frequent flu-like illnesses
with stroke. Stroke 40, 3206–3210 (2009).
29. Sfyroeras, G. S., Roussas, N., Saleptsis, V. G.,
Argyriou, C. & Giannoukas, A. D. Association between
periodontal disease and stroke. J. Vasc. Surg. 55,
1178–1184 (2012).
30. Haider, A. W. et al. The association of seropositivity to
Helicobacter pylori. Chlamydia pneumoniae, and
cytomegalovirus with risk of cardiovascular disease:
a prospective study. J. Am. Coll. Cardiol. 40, 1408–
1413 (2002).
31. Aiello, A. E. et al. Socioeconomic and
psychosocial gradients in cardiovascular
pathogen burden and immune response: the
multi-ethnic study of atherosclerosis. Brain
Behav. Immun. 23, 663–671 (2009).
32. Nagel, M. A. et al. Varicella zoster virus
vasculopathy: analysis of virus-infected arteries.
Neurology. 77, 364–370 (2011).
33. Sico, J. J. et al. HIV status and the risk of
ischemic stroke among men. Neurology 84,
1933–1940 (2015).
34. Islam, F. M., Wu, J., Jansson, J. & Wilson, D. P.
Relative risk of cardiovascular disease among
people living with HIV: a systematic review and
meta- analysis. HIV Med. 13, 453–468 (2012).
35. Gutierrez, J. et al. Brain arterial remodeling
contribution to nonembolic brain infarcts in
patients with HIV. Neurology 85, 1139–1145
(2015).
36. Di Napoli, M. & Papa, F. Inflammation, hemostatic
markers, and antithrombotic agents in relation to
long-term risk of new cardiovascular events in
first- ever ischemic stroke patients. Stroke 33,
1763–1771 (2002).
37. Pearson, T. A. et al. Markers of inflammation and
cardiovascular disease: application to clinical and
public health practice: a statement for healthcare
professionals from the Centers for Disease Control
and Prevention and the American Heart Association.
Circulation 107, 499–511 (2003).
38. Ridker, P. M., Cushman, M., Stampfer, M. J.,
Tracy, R. P. & Hennekens, C. H. Inflammation,
aspirin, and the risk of cardiovascular disease in
apparently healthy men. N. Engl. J. Med. 336,
973–979 (1997).
39. Ridker, P. M., Rifai, N., Rose, L., Buring, J. E. &
Cook, N. R. Comparison of C-reactive protein
and low-density lipoprotein cholesterol levels
in the prediction of first cardiovascular events.
N. Engl. J. Med. 347, 1557–1565 (2002).
This study provides evidence that hsCRP is a
strong independent predictor of first-time stroke.
40. Ridker, P. M., Buring, J. E., Shih, J., Matias, M. &
Hennekens, C. H. Prospective study of
C-reactive protein and the risk of future
cardiovascular events among apparently healthy
women. Circulation 98, 731–733 (1998).
41. Salazar, J. et al. C-reactive protein: clinical
and epidemiological perspectives. Cardiol. Res.
Pract. 2014, 605810 (2014).
42. Ji, S. R. et al. Cell membranes and liposomes
dissociate C-reactive protein (CRP) to form a new,
biologically active structural intermediate: mCRP(m).
FASEB J. 21, 284–294 (2007).
43. Eisenhardt, S. U. et al. Dissociation of pentameric
to monomeric C-reactive protein on activated
platelets localizes inflammation to
atherosclerotic plaques. Circ. Res. 105, 128–
137 (2009).
44. Shrive, A. K. et al. Three dimensional structure
of human C-reactive protein. Nat. Struct.
Biol. 3, 346–354 (1996).
45. Thompson, D., Pepys, M. B. & Wood, S. P. The
physiological structure of human C-reactive protein
and its complex with phosphocholine. Structure
7, 169–177 (1999).
46. Fujita, Y. et al. Oxidized LDL receptor LOX-1 binds
to C-reactive protein and mediates its vascular
effects. Clin. Chem. 55, 285–294 (2009).
47. Fujita, Y. et al. Lectin-like oxidized LDL receptor 1
is involved in CRP-mediated complement
activation. Clin. Chem. 57, 1398–1405 (2011).
48. Libby, P. Inflammation in atherosclerosis.
Arterioscler. Thromb. Vasc. Biol. 32, 2045–
2051 (2012).
49. The Emerging Risk Factors Collaboration.
C-reactive protein concentration and risk of
coronary heart disease, stroke, and mortality:
an individual participant meta-analysis. Lancet
375, 132–140 (2010).
This meta-analysis provides strong evidence of the
association between hsCRP and stroke.
50. Zhou, Y., Han, W., Gong, D., Man, C. & Fan, Y.
Hs-CRP in stroke: a meta-analysis. Clin. Chim.
Acta 453, 21–27 (2016).
51. Curb, J. D. et al. C-reactive protein and the future
risk of thromboembolic stroke in healthy men.
Circulation 107, 2016–2020 (2003).
52. Elkind, M. S. et al. High-sensitivity C-reactive
protein predicts mortality but not stroke: the
Northern Manhattan Study. Neurology 73,
1300–1307 (2009).
53. Luna, J. M. et al. High-sensitivity C-reactive
protein and interleukin-6-dominant inflammation and
ischemic stroke risk the Northern Manhattan Study.
Stroke 45, 979–987 (2014).
54. van Dijk, E. J. et al. C-reactive protein and
cerebral small-vessel disease: the Rotterdam
Scan Study. Circulation 112, 900–905 (2005).
55. Bos, M. J. et al. High serum C-reactive protein level
is not an independent predictor for stroke: the
Rotterdam Study. Circulation 114, 1591–1598
(2006).
56. Zacho, J. et al. Genetically elevated C-reactive protein
and ischemic vascular disease. N. Engl. J. Med. 359,
1897–1908 (2008).
57. Ridker, P. M. et al. Loci related to
metabolic-syndrome pathways including
LEPR,HNF1A, IL6R, and GCKR associate with
plasma C-reactive protein: the Women’s Genome
Health Study. Am. J. Hum. Genet. 82, 1185–
1192 (2008).
58. Fornage, M. et al. Biomarkers of inflammation and
MRI-defined small vessel disease of the brain: the
Cardiovascular Health Study. Stroke 39, 1952–1959
(2008).
59. Elkind, M. S., Tai, W., Coates, K., Paik, M. C. &
Sacco, R. L. High-sensitivity C-reactive
protein, lipoprotein-associated
phospholipase A2, and outcome after ischemic
stroke. Arch. Intern. Med. 166, 2073–2080
(2006).
60. Woodward, M. et al. Associations of inflammatory
and hemostatic variables with the risk of recurrent
stroke. Stroke 36, 2143–2147 (2005).
61. Welsh, P. et al. Associations of proinflammatory
cytokines with the risk of recurrent stroke. Stroke 39,
2226–2230 (2008).
62. Elkind, M. S. V. et al. C-reactive protein as a
prognostic marker after lacunar stroke: levels of
inflammatory markers in treatment of stroke. Stroke
45, 707–716 (2014).
This study provides evidence from a multicenter
stroke trial of the association between hsCRP and
recurrent stroke among lacunar stroke patients.
63. Schuett, H., Luchtefeld, M., Grothusen, C., Grote, K.
& Schieffer, B. How much is too much? Interleukin-6
and its signalling in atherosclerosis. Thromb. Haemost.
102, 215–222 (2009).
64. C Reactive Protein Coronary Heart Disease
Genetics Collaboration (CCGC). Association
between C reactive protein and coronary heart
disease: mendelian randomisation analysis based on
individual participant data. BMJ 342, d548 (2011).
65. IL6R Genetics Consortium Emerging Risk Factors
Collaboration. Interleukin-6 receptor pathways in
coronary heart disease: a collaborative meta-analysis
of 82 studies. Lancet 379, 1205–1213 (2012).
66. Interleukin-6 Receptor Mendelian
Randomisation Analysis (IL6R MR) Consortium.
The interleukin-6 receptor as a target for
prevention of coronary heart disease: a mendelian
randomisation analysis. Lancet 379, 1214–1224
(2012).
This Mendelian randomization analysis suggests a
causal association between IL-6 and cardiovascular
disease.
67. Kaptoge, S. et al. Inflammatory cytokines and risk
of coronary heart disease: new prospective study
and updated meta-analysis. Eur. Heart J. 35,
578–589 (2014).
68. Patterson, C. C. et al. The associations of
interleukin-6 (IL-6) and downstream inflammatory
markers with risk of cardiovascular disease: the
Caerphilly Study. Atherosclerosis 209, 551–557
(2010).
REVIEWS
69. Solomon, D. H. et al. Cardiovascular risk in
rheumatoid arthritis: comparing TNF-α blockade with
nonbiologic DMARDs. Am. J. Med. 126, 730. e9
—730.e17 (2013).
70. Marks, J. L. & Edwards, C. J. Protective effect of
methotrexate in patients with rheumatoid arthritis
and cardiovascular comorbidity. Ther. Adv.
Musculoskelet. Dis. 4, 149–157 (2012).
71. Rosenson, R. S. & Stafforini, D. M. Modulation of
oxidative stress, inflammation, and atherosclerosis
by lipoprotein-associated phospholipase A2. J. Lipid
Res. 53, 1767–1782 (2012).
72. Oei, H. H. et al. Lipoprotein-associated
phospholipase A2 activity is associated with risk
of coronary heart disease and ischemic stroke:
the Rotterdam Study. Circulation 111, 570–575
(2005).
73. Katan, M. et al. Lipoprotein-associated phospholipase
A2 is associated with atherosclerotic stroke risk: the
Northern Manhattan Study. PLoS ONE 9, e83393
(2014).
74. Elkind, M. S., Tai, W., Coates, K., Paik, M. C. &
Sacco, R. L. Lipoprotein-associated phospholipase A2
activity and risk of recurrent stroke. Cerebrovasc. Dis.
27, 42–50 (2009).
75. Ballantyne, C. M. et al. Lipoprotein-associated
phospholipase A2, high-sensitivity C-reactive
protein, and risk for incident ischemic stroke in
middle-aged men and women in the
Atherosclerosis Risk in Communities (ARIC)
Study. Arch. Intern. Med. 165, 2479–2484
(2005).
76. Ridker, P. M., MacFadyen, J. G., Wolfert, R. L. &
Koenig, W. Relationship of lipoprotein-associated
phospholipase A2 mass and activity with incident
vascular events among primary prevention
patients allocated to placebo or to statin therapy:
an analysis from the JUPITER trial. Clin. Chem.
58, 877–886 (2012).
77. Stein, E. A. Lipoprotein-associated phospholipase A2
measurements: mass, activity, but little productivity.
Clin. Chem. 58, 814–817 (2012).
78. Mohler, E. R. et al. The effect of darapladib on
plasma lipoprotein-associated phospholipase A2
activity and cardiovascular biomarkers in patients
with stable coronary heart disease or coronary
heart disease risk equivalent: the results of a
multicenter, randomized, double-blind,
placebo-controlled study. J. Am. Coll. Cardiol. 51,
1632–1641 (2008).
79. O’Donoghue, M. L. et al. Effect of darapladib on
major coronary events after an acute coronary
syndrome: the SOLID-TIMI 52 randomized
clinical trial. JAMA 312, 1006–1015 (2014).
80. The Lp-PLA2 Studies Collaboration.
Lipoprotein- associated phospholipase A2 and
risk of coronary disease, stroke, and mortality:
collaborative analysis of 32 prospective studies.
Lancet 375, 1536–1544 (2010).
This article includes a meta-analysis that supports
the association between LP-PLa2 and stroke.
81. Schillinger, M. et al. Inflammation and Carotid
Artery—Risk for Atherosclerosis Study
(ICARAS). Circulation 111, 2203–2209
(2005).
82. Elkind, M. S. et al. Tumor necrosis factor
receptor levels are associated with carotid
atherosclerosis. Stroke 33, 31–37 (2002).
83. Kolominsky-Rabas, P. L., Weber, M., Gefeller, O.,
Neundoerfer, B. & Heuschmann, P. U. Epidemiology of
ischemic stroke subtypes according to TOAST criteria:
incidence, recurrence, and long-term survival in
ischemic stroke subtypes: a population-based
study. Stroke 32, 2735–2740 (2001).
84. White, H. et al. Ischemic stroke subtype
incidence among whites, blacks, and Hispanics:
the Northern Manhattan Study. Circulation
111, 1327–1331 (2005).
85. Warlow, C. MRC European Carotid Surgery Trial:
interim results for symptomatic patients with
severe (70–99%) or with mild (0–29%) carotid
stenosis. Lancet 337, 1235–1243 (1991).
86. North American Symptomatic Carotid
Endarterectomy Trial Collaborators. Beneficial
effect of carotid endarterectomy in symptomatic
patients with high- grade carotid stenosis. N.
Engl. J. Med. 325, 445–453 (1991).
87. Cao, J. J. et al. C-reactive protein, carotid
intima- media thickness, and incidence of ischemic
stroke in the elderly: the Cardiovascular Health
Study. Circulation 108, 166–170 (2003).
88. Alvarez Garcia, B., Ruiz, C., Chacon, P., Sabin, J. A.
& Matas, M. High-sensitivity C-reactive protein in
high- grade carotid stenosis: risk marker for
 unstable carotid plaque. J. Vasc. Surg. 38, 1018– 1024 (2003).

NATURE REVIEWS | NEUROLOGY VOLUME 12 | OCTOBER 2016 | 603

.
d
REVIEWS
89. Mauriello, A. et al. A pathobiologic link between
risk factors profile and morphological markers of
carotid instability. Atherosclerosis 208, 572–580
(2010).
90. Rizzo, M. et al. Prediction of cardio- and
cerebro- vascular events in patients with
subclinical carotid atherosclerosis and low
HDL-cholesterol. Atherosclerosis 200, 389–
395 (2008).
91. Belfer, I. et al. Linkage of large-vessel carotid
atherosclerotic stroke to inflammatory genes via
a systematic screen. Int. J. Stroke 5, 145–151
(2010).
92. Wong, L. K. Global burden of intracranial
atherosclerosis. Int. J. Stroke 1, 158–159 (2006).
93. Chimowitz, M. I. et al. Stenting versus
aggressive medical therapy for intracranial
arterial stenosis. N. Engl. J. Med. 365, 993–
1003 (2011).
94. Arenillas, J. F. et al. Progression of symptomatic
intracranial large artery atherosclerosis is associated
with a proinflammatory state and impaired
fibrinolysis. Stroke 39, 1456–1463 (2008).
95. Miwa, K. et al. Association between interleukin-6
levels and first-ever cerebrovascular events in
patients with vascular risk factors. Arterioscler.
Thromb. Vasc. Biol. 33, 400–405 (2013).
96. Hoshi, T. et al. Relations of serum
high-sensitivity C-reactive protein and
interleukin-6 levels with silent brain infarction.
Stroke 36, 768–772 (2005).
97. Reganon, E. et al. Association between
inflammation and hemostatic markers in
atherothrombotic stroke. Thromb. Res. 112,
217–221 (2003).
98. Satizabal, C. L., Zhu, Y. C., Mazoyer, B., Dufouil, C.
& Tzourio, C. Circulating IL-6 and CRP are
associated with MRI findings in the elderly: the
3C-Dijon Study. Neurology 78, 720–727
(2012).
99. Wright, C. B. et al. Inflammatory biomarkers of
vascular risk as correlates of leukoariosis. Stroke 40,
3466–3471 (2009).
100. Rouhl, R. P. et al. Vascular inflammation in
cerebral small vessel disease. Neurobiol. Aging 33,
1800–1806 (2012).
101. Gao, S. P. et al. Is inflammation linked to
thrombogenesis in atrial fibrillation? Int. J. Cardiol.
149, 260–261 (2011).
102. Marott, S. C. et al. Does elevated C-reactive
protein increase atrial fibrillation risk? A
Mendelian randomization of 47,000 individuals from
the general population. J. Am. Coll. Cardiol. 56,
789–795 (2010).
103. Chung, M. K. et al. C-reactive protein elevation
in patients with atrial arrhythmias:
inflammatory mechanisms and persistence of
atrial fibrillation. Circulation 104, 2886–2891
(2001).
104. Conway, D. S., Buggins, P., Hughes, E. & Lip, G. Y.
Relationship of interleukin-6 and C-reactive protein
to the prothrombotic state in chronic atrial
fibrillation. J. Am. Coll. Cardiol. 43, 2075–2082
(2004).
105. Ederhy, S. et al. C-reactive protein and
transesophageal echocardiographic markers of
thromboembolism in patients with atrial fibrillation.
Int. J. Cardiol. 159, 40–46 (2012).
106. Kamel, H. et al. Electrocardiographic left atrial
abnormality and risk of stroke: Northern
Manhattan Study. Stroke 46, 3208–3212
(2015).
107. Kamel, H., Okin, P., Elkind, M. S. & Iadecola, C.
Atrial fibrillation and mechanisms of stroke: time for
a new model. Stroke 47, 895–900 (2016).
108. Ford, E. S. Does exercise reduce inflammation?
Physical activity and C-reactive protein among U. S.
adults. Epidemiology 13, 561–568 (2002).
109. Sacco, R. L. et al. Leisure-time physical activity
and ischemic stroke risk: the Northern Manhattan
Stroke Study. Stroke 29, 380–387 (1998).
110. Lee, I. M., Hennekens, C. H., Berger, K., Buring, J.
E. & Manson, J. E. Exercise and risk of stroke in
male physicians. Stroke 30, 1–6 (1999).
111. Esposito, K. et al. Effect of a mediterranean-style
diet on endothelial dysfunction and markers of
vascular inflammation in the metabolic
syndrome: a randomized trial. JAMA 292,
1440–1446 (2004).
112. Serrano-Martinez, M. et al. A Mediterranean
dietary style influences TNF-α and VCAM-1
coronary blood levels in unstable angina patients.
Eur. J. Nutr. 44, 348–354 (2005).
113. Salas-Salvado, J. et al. Components of
the Mediterranean-type food pattern and
serum
inflammatory markers among patients at high risk for
cardiovascular disease. Eur. J. Clin. Nutr. 62, 651–659
(2008).
114. Lopez-Garcia, E. et al. Major dietary patterns are
related to plasma concentrations of markers of
inflammation and endothelial dysfunction. Am. J. Clin.
Nutr. 80, 1029–1035 (2004).
115. Estruch, R. et al. Primary prevention of cardiovascular
disease with a Mediterranean diet. N. Engl. J. Med.
368, 1279–1290 (2013).
116. Gao, X., Bermudez, O. I. & Tucker, K. L. Plasma
C-reactive protein and homocysteine concentrations
are related to frequent fruit and vegetable intake in
Hispanic and non-Hispanic white elders. J. Nutr. 134,
913–918 (2004).
117. Nichol, K. L. et al. Influenza vaccination and reduction
in hospitalizations for cardiac disease and stroke
among the elderly. N. Engl. J. Med. 348, 1322–1332
(2003).
118. Clar, C., Oseni, Z., Flowers, N., Keshtkar-Jahromi, M.
& Rees, K. Influenza vaccines for preventing
cardiovascular disease. Cochrane Database Syst. Rev.
5, CD005050 (2015).
119. Smeeth, L. et al. Risk of myocardial infarction and
stroke after acute infection or vaccination. N. Engl. J.
Med. 351, 2611–2618 (2004).
120. Lavallée, P., Perchaud, V., Gautier-Bertrand, M.,
Grabli, D. & Amarenco, P. Association between
influenza vaccination and reduced risk of brain
infarction. Stroke 33, 513–518 (2002).
This article recommends influenza vaccination to
prevent secondary cardiovascular risk, and reviews the
evidence for this recommendation.
121. Davis, M. M. et al. Influenza vaccination as secondary
prevention for cardiovascular disease: a science
advisory from the American Heart Association/
American College of Cardiology. Circulation 114,
1549–1553 (2006).
122. Gurfinkel, E. P., de la Fuente, R. L., Mendiz, O. &
Mautner, B. Influenza vaccine pilot study in acute
coronary syndromes and planned percutaneous
coronary interventions: the FLU Vaccination Acute
Coronary Syndromes (FLUVACS) Study. Circulation
105, 2143–2147 (2002).
123. Tseng, H. F. et al. Pneumococcal vaccination and risk
of acute myocardial infarction and stroke in men.
JAMA 303, 1699–1706 (2010).
124. Wolf, D., Zirlik, A. & Ley, K. Beyond vascular
inflammation-recent advances in understanding
atherosclerosis. Cell. Mol. Life Sci. 72, 3853–3869
(2015).
125. Cannon, C. P. et al. Antibiotic treatment of
Chlamydia pneumoniae after acute coronary
syndrome. N. Engl. J. Med. 352, 1646–1654
(2005).
126. Grayston, J. T. et al. Azithromycin for the secondary
prevention of coronary events. N. Engl. J. Med. 352,
1637–1645 (2005).
127. Andraws, R., Berger, J. S. & Brown, D. L. Effects of
antibiotic therapy on outcomes of patients with
coronary artery disease: a meta-analysis of randomized
controlled trials. JAMA 293, 2641–2647 (2005).
This meta-analysis concludes that primary
prevention treatment with rosuvastatin in high-risk
patients stratified using hsCRP levels can improve
outcomes.
128. Ridker, P. M. et al. Rosuvastatin to prevent vascular
events in men and women with elevated C-reactive
protein. N. Engl. J. Med. 359, 2195–2207 (2008).
129. Davignon, J. Beneficial cardiovascular pleiotropic
effects of statins. Circulation 109, (Suppl. 1)
III-39—III-43 (2004).
130. Chen, H., Ikeda, U., Shimpo, M. & Shimada, K.
Direct effects of statins on cells primarily involved in
atherosclerosis. Hypertens. Res. 23, 187–192
(2000).
131. Comparato, C. et al. Clinically relevant pleiotropic
effects of statins: drug properties or effects of
profound cholesterol reduction? Nutr. Metab.
Cardiovasc. Dis. 11, 328–343 (2001).
132. Rasmussen, L. M. et al. Diverse effects of inhibition of
3-hydroxy-3-methylglutaryl-CoA reductase on the
expression of VCAM-1 and E-selectin in endothelial
cells. Biochem. J. 360, 363–370 (2001).
133. Hurlimann, D. et al. Anti-tumor necrosis
factor-α treatment improves endothelial
function in patients with rheumatoid arthritis.
Circulation 106, 2184–2187 (2002).
134. Rayment, N. B. et al. Synthesis of TNFα and TGFβ
mRNA in the different micro-environments within
atheromatous plaques. Cardiovasc. Res. 32,
1123–1130 (1996).
135. Ridker, P. M. Testing the inflammatory hypothesis
of atherothrombosis: scientific rationale for
the cardiovascular inflammation reduction trial
(CIRT).
J. Thromb. Haemost. 7 (Suppl. 1), 332–339 (2009).
136. Ridker, P. M., Thuren, T., Zalewski, A. & Libby,
P. Interleukin-1β inhibition and the prevention
of recurrent cardiovascular events: rationale and
design of the Canakinumab Anti-inflammatory
Thrombosis Outcomes Study (CANTOS). Am.
Heart J. 162, 597–605 (2011).
137. Salminen, A. & Kaarniranta, K. AMP-activated
protein kinase (AMPK) controls the aging
process via an integrated signaling network.
Ageing Res. Rev. 11, 230–241 (2012).
138. Ricote, M., Li, A. C., Willson, T. M., Kelly, C.
J. & Glass, C. K. The peroxisome
proliferator-activated receptor-γ is a negative
regulator of macrophage activation. Nature
391, 79–82 (1998).
139. Li, A. C. et al. Differential inhibition of
macrophage foam-cell formation and
604 | OCTOBER 2016 | VOLUME 12
.
d
atherosclerosis in mice by PPARα, β/δ, and γ. J.
Clin. Invest. 114, 1564–1576 (2004).
140. Zelvyte, I., Dominaitiene, R., Crisby, M. &
Janciauskiene, S. Modulation of
inflammatory mediators and PPARγ and
NFκB expression by pravastatin in response
to lipoproteins in human monocytes in vitro.
Pharmacol. Res. 45, 147–154 (2002).
141. White, G. E., Iqbal, A. J. & Greaves, D. R. CC
chemokine receptors and chronic
inflammation— therapeutic opportunities
and pharmacological challenges.
Pharmacol. Rev. 65, 47–89 (2013).
142. Kleinbongard, P., Heusch, G. & Schulz, R. TNFα
in atherosclerosis, myocardial
ischemia/reperfusion and heart failure.
Pharmacol. Ther. 127, 295–314 (2010).
Acknowledgements
The authors acknowledge funding support for work
described in this review from the National Institute of
Neurological Disorders and Stroke (NINDS R01 NS29993,
R01 NS050724, T32 NS07153); the Bristol-Myers
Squibb–Sanofi Partnership and diaDexus; and the
American Heart Association (Grant-in-Aid 0355596T;
Kathleen Scott Fellowship).
Author contributions
C.C.E. researched data for the article. Both authors wrote
the article, made substantial contributions to
discussion of the content and reviewed and/or edited
the manuscript before submission.
Competing interests
M.S.E received research support from the Bristol-Myers
Squibb–Sanofi Partnership and diaDexus, Inc.; royalties from
UpToDate for chapters related to cryptogenic stroke and
hemicraniectomy; receives compensation for providing con-
sultative services for Biotelemetry (Cardionet), the
Bristol- Myers Squibb–Pfizer Partnership, Boehringer–
Ingelheim, and the Sanofi–Regeneron Partnership; serves
as the lead Principal Investigator for a Biogen IDEC study
of Tysabri® and stroke; and has given expert legal opinions
on behalf of Merck (NuvaRing® and stroke litigation),
BMS-Sanofi Pharmaceutical Partnership (clopidogrel and
stroke litiga- tion), and Hi-Tech Pharmaceuticals
(dimethylamylamine and stroke litigation). C.C.E. declares
no competing interests.
Review criteria
We searched the PubMed database between the years
1995 and 2016 for the following terms individually or in
combina- tion: “stroke”, “inflammation”, “inflammatory
markers”, “stroke subtypes”, “C-reactive protein”,
“interleukin-6”, “lipo- protein-associated phospholipase
A2” and their abbrevia- tions. We excluded abstracts
without available full text articles and non-English texts.
Of these, we further excluded articles which were not
relevant to this review and reviewed references from
those we thought were relevant, to further identify more
articles.
www.nature.com/nrneurol