Biomarkers of Remote Ischaemic Conditioning in Stroke and Cerebral Small Vessel Disease: A Narrative Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is an interesting narrative review on the content and value of biomarkers of remote ischemic conditioning as one treatment modality in patients with stroke  and or cerebral small vessel disease. Methodology is well designed, biomarkers are explained/described in detail, conclusions are justified, literature is well chosen.

A few additional modifications and comments would add value to the paper.

It would be very helpful for the reader if authors summarized the text in lines 462-569 in the form of a table or two as a guide between disease and biomarkers and their etiology.

Author Response

It would be very helpful for the reader if authors summarized the text in lines 462-569 in the form of a table or two as a guide between disease and biomarkers and their etiology.

 

• Many thanks for your comment, we have already actioned this and created a very indepth table, summarising every biomarker, we attached this as a supplementary file as the table we feel will be too long to attach in the manuscript. We have mentioned more on the biomarkers function as well as including their diagnostic and prognostic capabilities 

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript is well written. Authors analyze the role of biomarkers in stroke and cerebral small vessel diseases. 

Biomarkers play an important role in several diseases to early diagnosis, monitoring and treatment.

Authors could add informations about  the role of anticoagulant factors in stroke and other cerebral diseases (if data exist). 

Author Response

Authors could add informations about  the role of anticoagulant factors in stroke and other cerebral diseases (if data exist). 

We thank the reviewer for this constructive suggestion. We note that the manuscript already contains a dedicated section discussing coagulation dynamics, clot microstructure (including fractal dimension), and conventional haemostatic markers in the context of RIC and stroke.

We agree, however, that greater clarity regarding endogenous anticoagulant pathways would strengthen the framing of this discussion. To address this, we have now added the following clarifying sentence to emphasise their relevance:

“Markers of coagulation, endogenous anticoagulant pathways, and platelet function are likely to be of particular importance when measuring the effect of RIC on recurrent stroke.”

We believe this addition more explicitly highlights the importance of anticoagulant mechanisms while maintaining the focus and scope of the manuscript.

We have added this in lines 323-325, please note this whole section is about anticoagulant factors (323-363)

Reviewer 3 Report

Comments and Suggestions for Authors

This review manuscript summarizes the current knowledge on various potential biomarkers of remote ischemic conditioning in stroke and cerebral small-vessel diseases. The work is comprehensive and should be of interest to a broad readership in the research area. However, some concerns should be addressed before publication.

1. Most cited studies are based on patients. Authors should also include whether there are related longitudinal studies using animals to validate the listed biomarkers.
2. It is unclear whether the listed subtitles “Neuronal injury”, “Inflammation”, “MMPs”…., and “Lipids” are all identified as “Serum biomarkers”. If yes, the manuscript should highlight different categories of biomarkers (Serum biomarkers, imaging biomarkers, ...” with bold words.  
3. Another major source of biomarkers is cerebral spinal fluid (CSF), but the manuscript didn’t mention it.

Some minor issues related to grammar, formatting, and typing are identified:

• Some sentences have grammatical issues, such as line 82, “…researchers in choosing appropriate biomarkers their study design”. The manuscript needs to be completely checked for any typos or grammatical errors.
• The beginning of many paragraphs contains unknown words such as “Group 59346, Grouped object”.

Comments on the Quality of English Language

Editing and quality checks are needed.

Author Response

1. Most cited studies are based on patients. Authors should also include whether there are related longitudinal studies using animals to validate the listed biomarkers.

Thank you we have now included 2 longitudinal animal studies and added sentences 582-598 to strengthen our discussion.

 

2. It is unclear whether the listed subtitles “Neuronal injury”, “Inflammation”, “MMPs”…., and “Lipids” are all identified as “Serum biomarkers”. If yes, the manuscript should highlight different categories of biomarkers (Serum biomarkers, imaging biomarkers, ...” with bold words.  

Thank you for your comment, we have now amended lines 117- 124 to specifically highlight this.

We have also in our biomarker table in bold added whether the biomarker is serum/imaging etc and made this bold to also enhance its visibility and ensure clarity of which type of biomarker this is.

 

3. Another major source of biomarkers is cerebral spinal fluid (CSF), but the manuscript didn’t mention it.

Thank you for this comment. We have already discussed cerebrospinal fluid (CSF) biomarkers at multiple points in the manuscript (lines 131, 216, 517–520, 553–555, and 566–567), where they are presented in comparison to serum biomarkers to highlight their mechanistic relevance and potential translational value.

To further address the reviewer’s point, we have now added additional clarification in lines 568–570 outlining the practical and logistical challenges associated with CSF biomarker sampling, including invasiveness and limited feasibility for repeated measurements in clinical RIC trials.

Reviewer 4 Report

Comments and Suggestions for Authors

Kamarova et al. wrote an interesting narrative review on the role of biomarkers in Remote Ischemic Conditioning (RIC). The purpose of the paper is relevant, and the authors have done a very thorough job; however, several points should be revised before publication.

1. The authors should also classify the biomarkers from a practical perspective: are they diagnostic or prognostic biomarkers, or are they intended to assess treatment effects? Do they have other potential functions?
2. The Results section is far too long. Each paragraph is preceded by lengthy and often unnecessary introductions. The authors should limit the Results to what was actually found in the available literature.
3. The Discussion section should be substantially improved by providing a clear interpretation of the findings. The authors should explicitly discuss which biomarkers are the most promising for RIC evaluation, from which perspective (i.e., diagnostic, prognostic, etc.), and what limitations emerge from the current literature.
4. The authors should provide a clearer and more readable table or figure in which biomarkers are classified according to their typology (serum, CSF, others), their level of evidence for RIC, their biological significance, and related aspects. Table 1 is currently difficult to interpret.

 

Minor points

1. There are several mistakes throughout the text; these should be corrected.
2. Keywords are missing.
3. The included figures are not cited in the text.

Author Response

1. The Results section is far too long. Each paragraph is preceded by lengthy and often unnecessary introductions. The authors should limit the Results to what was actually found in the available literature.

Thank you for your comment. We have substantially cut this down, we have also ensured we cover the main findings from the study.

 

2. The Discussion section should be substantially improved by providing a clear interpretation of the findings. The authors should explicitly discuss which biomarkers are the most promising for RIC evaluation, from which perspective (i.e., diagnostic, prognostic, etc.), and what limitations emerge from the current literature.

Thank you, we have now amended the limitations and challenges section. We have added a section on the utilisation of biomarkers in terms of prognostic and diagnostic factors.

 

3.

The authors should provide a clearer and more readable table or figure in which biomarkers are classified according to their typology (serum, CSF, others), their level of evidence for RIC, their biological significance, and related aspects. Table 1 is currently difficult to interpret

Improve 

 

We have made this table better aligned, amended the formatting, added a section on serum markers etc aswell as added which markers have which role 

1. There are several mistakes throughout the text; these should be corrected.
2. Keywords are missing.
3. The included figures are not cited in the text.

We have gone through the whole manuscript and amended all the above comments.

 

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

All my concerns have been addressed.