A study of association of serum ferritin as a prognostic marker in acute cerebrovascular accident

Cerebrovascular disease (CVD) is the third leading cause of death in developed countries and is now emerging as the commonest preventable life-threatening neurological problem worldwide. It makes an important contribution to morbidity and mortality in developed as well as developing countries. The prognosis of acute stroke is determined by a series of factors some of which may be used in the early stages of stroke to predict prognosis and mortality. However, the role of inflammatory markers in predicting functional outcome in stroke remains controversial, Iron and ferritin are known to have an important role in stroke as well as in other disorders. Serum ferritin which is considered as an acute phase reactant has also been used for assessing the severity and prognosis of stroke. Therefore, testing of serum ferritin is useful in identifying high risk patients.1: To study the effect of level of serum ferritin with early neurological deterioration and the outcome in patients of acute stroke. 2: Association of serum ferritin in ischemic and haemorrhagic stroke.50 patients with acute stroke were selected based on inclusion and exclusion criteria. Appropriate questionnaire was used to collect the data of patients. Diagnosis of stroke was confirmed by CT or MRI scan of brain and examination was done by Canadian stroke scale at the time of admission. About 5ml of venous blood Sample from cubital vein was collected for measuring serum ferritin levels, it was performed within 48hrs of onset of symptoms by using CLIA method. Neurological assessment was repeated on the day of discharge to assess the clinical improvement and prognosis of the stroke patients.Totally 50 patients of acute stroke were included in our study, majority of the patients are males 35 (70%), and females are 15(30%). Approximately 36% were in the age group of 51-60 years. In this study ischemic stroke was seen in 45 (90%) of the patients and 5 (10%) had hemorrhagic stroke. The serum ferritin levels are normal in 41(82%) and high in 9(18%) of the patients. Canadian stroke scale interpretation on the day of discharge showed 20% of the patient are deteriorated, 66% are in the same status and 14% of the patients are improved clinically. The patients with haemorrhagic stroke had high serum ferritin level 60.0% and ischemic stroke are 13.3%. Those patients with high serum ferritin levels had higher deterioration in Canadian stroke scale (p<0.001). The mean serum ferritin levels are higher in deteriorated patients 199.29% when compared to other status group in Canadian stroke scale.High levels of serum ferritin correlates well with early neurological deterioration of stroke patients. Based on this study finding, that high serum ferritin level within 48 hours after the onset of symptoms of stroke helps to predict the early prognosis. Therefore, testing of serum ferritin is useful in identifying high risk patients.

Predictors of In-Hospital Mortality in Stroke Patients

Background: In-hospital mortality is a good indicator to assess the efficacy of stroke care. Identifying the predictors of in-hospital mortality is important to advance the stroke outcome and plan the future strategies of stroke management. Methods: This was a prospective observational study conducted at a tertiary referral center in Sri Lanka to identify the possible predictors of in-hospital mortality. The study included 246 confirmed stroke patients. The diagnosis of stroke was established on the clinical history, examination and neuroimaging. The differentiation of stroke in to haemorrhagic type and ischaemic type was based on the results of computed tomography. In all patients, demographic data, comorbidities, clinical signs (pulse rate, respiratory rate, systolic blood pressure, diastolic blood pressure, on admission Glasgow Coma Scale (GCS) score) and imaging findings were recorded. Serum electrolyte test was performed in all stroke patients and hyponatremia was defined as serum Na+ less than 131mmol/l. All patients were followed up throughout their hospital course and the in-hospital mortality was recorded. In hospital mortality was defined as the deaths which occurred due to stroke after 24 hours of hospital admission. Results: The incidence of in-hospital mortality was 11.7% (95% confidence interval 8-16.4). The mean day of in-hospital deaths to occur was 5.9 days (SD±3.8 Min 2 Max 20). According to multivariate logistic regression analysis on admission GCS score (Odds Ratio (OR)-0.71) and haemorrhagic stroke type (OR-5.12) predict the in-hospital mortality. The area under the curve of receiver operating curve drawn for the on admission GCS score was 0.78 with a sensitivity of 96.31% and specificity of 41.38% for a patient presented with the GCS score of <10. Conclusion: On admission GCS and haemorrhagic stroke are independent predictors of in-hospital mortality. Patients with on admission GCS <10 have a moderate predictive ability in predicting the in-hospital mortality. Thus, a special attention should be given to the patients with low GCS score and haemorrhagic strokes for reducing rates of in-hospital mortality.

Decision-Making Process for the Management of Acute Stroke in Patients on Oral Anticoagulant: From Guidelines to Clinical Routine

Background: The occurrence of both ischaemic (IS) and haemorrhagic stroke in patients on anticoagulation is a major issue due to the frequency of their prescriptions in westernised countries and the expected impact of anticoagulant activity on recanalization during an IS or on the outcomes associated with intracerebral haemorrhage (ICH). Several guidelines are available but sometimes differ in their conclusions or regarding specific issues, and their application in routine emergency settings may be limited by particular individual issues or heterogeneous local specificities.Methods: Based on the current guidelines and additional published data, the algorithms proposed in this paper aim to help the decision-making process regarding stroke management in the setting of concurrent anticoagulants by addressing specific clinical situations based on clinical variables commonly encountered in real-world practise.Results: For patients on non–vitamin K oral anticoagulants, reversion can be achieved with specific antidotes, but only idarucizumab, the specific dabigatran antidote, is indicated in both IS and ICH. Due to the low risk of a prothrombotic effect, idarucizumab can be immediately used in IS patients eligible for thrombolysis before the dabigatran concentration is known. To optimise ICH management, the time since symptom onset, with thresholds proposed at 6 and 9 hours based on the expected timing of haematoma expansion, could also to be taken into account.Conclusions: Anticoagulant reversal in patients presenting with a stroke remains a major issue, and algorithms based on a step-by-step approach may be useful for clinical practise. Real-life studies strongly support the benefits of idarucizumab availability in stroke units and emergency departments.

Surgical results for hypertensive intracerebral hemorrhagesdepending on intervention timing

Study aim. To analyse the surgical outcomes in patients with haemorrhagic stroke depending on the timing of surgery. Materials and methods. We performed a retrospective analysis of 500 patients (335 (67%) men and 165 (33%) women), who underwent surgical treatment of hypertensive intracranial hemorrhages at the N.V. Sklifosovsky Research Institute for Emergency Medicine between 1997 and 2020. The mean patient age was 53.1 12.2 years. The mean time until surgery was 3.3 2.6 days. Outcomes were assessed on day 30 from disease onset using the modified Rankin Scale (mRS). Results. In the total sample, outcomes as measured by the mRS were as follows: type 0 84 (16.8%) patients, type 1 37 (7.4%), type 2 46 (9.2%), type 3 38 (7.6%), type 4 43 (8.6%), type 5 142 (28.4%) and type 6 110 (22.0%). Treatment results were better when surgery was delayed (2 = 64.4; p 0.00001). Mortality was 36.4% after surgery conducted in the first day after haemorrhage, while mRS scores of 02 made up 18.6%. Mortality was 20.4% after surgery conducted on the second or third day, and mRS scores of 02 made up 29.6%. Mortality was 17.4% after surgery conducted on day 47, and mRS scores of 02 outcomes were present in 49.0% of subjects. Mortality was 8.8% when surgery was performed on day 8 or later, and favourable outcomes were present in 48.5% of patients. Conclusion. Intracerebral haematoma excision on day 23 leads to better outcomes in patients with reduced levels of alertness up to sopor, while surgery after day 3 leads to better results in alert patients and those with obtundation.

CLINICAL AND ELECTROPHYSIOLOGICAL INDICATORS OF ACUTE AND EARLY RECOVERY PERIODS OF CEREBRAL STROKE

В остром и раннем восстановительном периодах церебрального инсульта взаимосвязь между биоэлектрической активностью головного мозга и клинической картиной заболевания представляют значительный научный и практический интерес. В данной статье, представлены результаты исследования клинико-неврологических и электроэнцефалографических показателей, в остром и раннем восстановительном периодах церебрального инсульта, 67 больных в возрасте от 43 до 78 лет. Показано, что у больных в остром и раннем восстановительном периодах церебрального инсульта на фоне двигательных и речевых расстройств, наблюдались легкие и умеренные когнитивные нарушения, а также тревожно-депрессивные проявления. Головная боль, соответствующая критериям головной боли напряжения отмечалась у 61,1% больных. Биоэлектрическая активность головного мозга характеризовалась выраженной дельта и тета активностью, а также единичными острыми волнами, спайками, преимущественно в пораженном полушарии головного мозга, межполушарной асимметрией, повышением мощности спектров в сторону преобладания медленных волн. Показатели индекса когерентности по всем отведениям были снижены, что свидетельствует о нарушении функциональных межполушарных взаимосвязей. Более значительное повышение индекса когерентности в дельта и тета диапазонах у пациентов, перенесших геморрагический инсульт, может указывать на более грубые межполушарные нарушения, в сравнении с ишемическим инсультом. In the acute and early recovery periods of cerebral stroke, the correlation between bioelectrical activity of the brain and the clinical picture of the disease is of considerable scientific and practical interest. This article presents the results of a study of clinical, neurological and electroencephalographic parameters, in the acute and early recovery periods of cerebral stroke, in 67 patients aged from 43 to 78. Mild and moderate cognitive impairment as well as anxiety and depressive manifestations were shown among patients in the acute and early recovery periods of cerebral stroke amid the motor and speech disorders. Headache meeting the criteria of tension headache was reported among 61,1% of patients. The bioelectrical activity of the brain was characterised by marked delta and theta activity as well as single sharp waves, commissures mainly in the affected cerebral hemisphere, interhemispheric asymmetry and by increase in the spectrum power towards the predominance of slow waves. The coherence index scores were decreased on all directions, indicating impaired functional interhemispheric connectivity. A greater increase in coherence index in the delta and theta bands among haemorrhagic stroke patients may indicate more severe interhemispheric disturbances compared to ischaemic stroke.

Prevalence of the Frank’s sign by aetiopathogenic stroke subtype: A prospective analysis

Background and purpose The Frank’s sign is a diagonal earlobe crease running from the tragus to the edge of the auricle at an angle of 45°. Many studies have associated this sign with coronary artery disease and some with cerebrovascular disease. The objective of this study was to analyse the prevalence of the Frank’s sign in patients suffering from acute stroke with a particular focus on its prevalence in each of the five aetiopathogenic stroke subtypes. Special interest is given to embolic stroke of undetermined source (ESUS), correlating the sign with clinical and radiological markers that support an underlying causal profile in this subgroup. Methods Cross-sectional descriptive study including 124 patients admitted consecutively to a stroke unit after suffering an acute stroke. The Frank’s sign was evaluated by the same blinded member of the research team from photographs taken of the patients. The stroke subtype was classified following SSS-TOAST criteria and the aetiological study was performed following the ESO guidelines. Results The Frank’s sign was present in 75 patients and was more prevalent in patients with an ischaemic stroke in comparison with haemorrhagic stroke (63.9 vs. 37.5, p<0.05). A similar prevalence was found in the different ischaemic stroke subtypes. The Frank’s sign was significantly associated with age, particularly in patients older than 70 who had vascular risk factors. Atherosclerotic plaques found in carotid ultrasonography were significantly more frequent in patients with the Frank’s sign (63.6%, p<0.05). Analysing the ESUS, we also found an association with age and a higher prevalence of the Frank’s sign in patients with vascular risk factors and a tendency to a high prevalence of atherosclerosis markers. Conclusion The Frank’s sign is prevalent in all aetiopathogenic ischaemic stroke subtypes, including ESUS, where it could be helpful in suspecting the underlying cardioembolic or atherothrombotic origin and guiding the investigation of atherosclerosis in patients with ESUS and the Frank’s sign.

Childhood strokes in China describing clinical characteristics, risk factors and performance indicators: a case-series study

AimTo investigate clinical characteristics, risk factors (RFs), neurologic deficits and medical care provided in children who had a stroke in China.MethodsWe conducted a retrospective case-series study using the medical records of children aged 1 month to 18 years with arterial ischaemic stroke (AIS) or haemorrhagic stroke (HS) (with the entry codes I60, I61, I62, I63 (ICD-10)), who were admitted to different hospitals in Beijing, between January 2018 and December 2018. We obtained the following information from the charts: demographic characteristics, clinical presentations, RFs for paediatric stroke, laboratory examination, neuroimaging records and neurologic sequelae.ResultsWe identified 312 first admissions for stroke (172 AIS and 140 HS). The mean age at onset was 8.6±3.9 years for patients who had an AIS and 8 (5–13) years for patients who had an HS. There were more males than females in both groups (AIS: 59.88% vs 40.12%; HS: 52.14% vs 47.86%). A known aetiology was identified in 92.44% and 86.43% of patients who had an AIS and HS, respectively. The leading cause of AIS was cerebrovascular diseases including moyamoya (68.6%), while that for HS was arteriovenous malformation (51.43%). The most common initial clinical presentation was hemiplegia (86.05%) in patients who had an AIS and headache (67.86%) in patients who had an HS. The use of healthcare, including acute treatment (antithrombotic in 17.44%, anticoagulant in 5.23%) and secondary prevention (antithrombotic in 6.39%, anticoagulant in 1.16%), varied and was significantly lower among patients who had an AIS. The most common complications were epilepsy (22.09%) and pneumonia (4.65%) in patients who had an AIS and epilepsy (17.14%) and hydrocephalus (12.14%) in patients who had an HS. Neurological deficits occurred in 62.8% of patients who had an AIS and 72.86% of patients who had an HS.ConclusionCerebral arteriopathy was a major RF for both AIS and HS in children living in China. Large epidemiological studies are required to identify RFs to prevent stroke as well as appropriate interventions.

Higher total white blood cell and neutrophil counts are associated with an increased risk of fatal stroke occurrence: the Guangzhou biobank cohort study

Background Chronic inflammatory diseases are linked to an increased risk of stroke events. The white blood cell (WBC) count is a common marker of the inflammatory response. However, it is unclear whether the WBC count, its subpopulations and their dynamic changes are related to the risk of fatal stroke in relatively healthy elderly population. Methods In total, 27,811 participants without a stroke history at baseline were included and followed up for a mean of 11.5 (standard deviation = 2.3) years. After review of available records, 503 stroke deaths (ischaemic 227, haemorrhagic 172 and unclassified 104) were recorded. Cox proportional hazards regression was used to assess the associations between the WBC count, its subpopulations and their dynamic changes (two-phase examination from baseline to the 1st follow-up) and the risk of fatal all stroke, fatal ischaemic stroke and fatal haemorrhagic stroke. Results (i) Regarding the WBC count in relation to the risk of fatal stroke, restricted cubic splines showed an atypically U-curved association between the WBC count and the risk of fatal all stroke occurrence. Compared with those in the lowest WBC count quartile (< 5.3*10^9/L), the participants with the highest WBC count (> 7.2*10^9/L) had a 53 and 67% increased risk for fatal all stroke (adjusted hazard ratio [aHR] = 1.53, 95% confidence interval (CI) 1.16–2.02, P = 0.003) and fatal haemorrhagic stroke (aHR = 1.67, 95% CI 1.10–2.67, P = 0.03), respectively; compared with those in the lowest quartile (< 3.0*10^9/L), the participants with the highest NEUT count (> 4.5*10^9/L) had a 45 and 65% increased risk for fatal all stroke (aHR = 1.45, 95% CI 1.10–1.89, P = 0.008) and fatal ischaemic stroke (aHR = 1.65, 95%CI 1.10–2.47 P = 0.02), respectively. With the additional adjustment for C-reactive protein, the same results as those for all stroke and ischaemic stroke, but not haemorrhagic stroke, were obtained for the WBC count (4 ~ 10*10^9/L) and the NEUT count (the NEUT counts in the top 1% and bottom 1% at baseline were excluded). (ii) Regarding dynamic changes in the WBC count in relation to the risk of fatal stroke, compared with the stable group (− 25% ~ 25%, dynamic changes from two phases of examination (baseline, from September 1st, 2003 to February 28th, 2008; 1st follow-up, from March 31st 2008 to December 31st 2012)), the groups with a 25% increase in the WBC count and NEUT count respectively had a 60% (aHR = 1.60, 95% CI 1.07–2.40, P = 0.02) and 45% (aHR = 1.45, 95% CI1.02–2.05, P = 0.04) increased risk of fatal all stroke occurrence. Conclusions The WBC count, especially the NEUT count, was associated with an increased risk of fatal all stroke occurrence. Longitudinal changes in the WBC count and NEUT count increase in excess of 25% were also associated with an increased risk of fatal all stroke occurrence in the elderly population.