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Zhu, Hazen and colleagues (a research team that was instrumental in recognizing the link between elevated TMAO levels and the development of cardiovascular-related events) noted that dietary choline and TMAO (a metabolite of choline and carnitine breakdown) produced greater stroke size and severity.[49] The team also found that transplanting gut microbes that contain an enzyme essential for choline-related TMAO production in the gut, called CutC , was enough to fuel increased stroke severity (over 2x larger!) and worsened outcomes (20-30% reduction in multiple functional outcome measures).[49] This study demonstrated for the first time the impact that the gut microbiome can have on stroke severity and functional impairment following stroke

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Neurochem 54 , 823827 (1990)

Other peripheral immune cells, such as neutrophils [260] and natural killer cells [52, 261,262,263], show associations with ALS and may influence future therapeutic targets [264]

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