Predictors of severity and outcome and roles of intravenous thrombolysis and biomarkers in first ischemic stroke

Aim: Stroke is one of the leading causes of death and disability. The proportion of patients receiving recombinant tissue plasminogen activator is low in our country. Biomarkers to identify patients at risk of severe disease, and guide treatment and prognosis would be valuable. This article aims to identify the factors that can independently prognosticate the acute phase of ischemic stroke.Methods: All patients with the first episode of ischemic stroke admitted to the Neurology Department between 1st December 2017 to 31st March 2018 were included in this pilot study. Stroke severity was evaluated using the National Institute of Health Stroke Scale (NIHSS). Patients being admitted within 4.5 h of onset of symptoms were thrombolysed with injection alteplase. For each patient, 4 serum biomarkers (D-dimer, fibrinogen, C-reactive protein and neuron specific enolase) were evaluated at admission and 24 h later. Discharged patients were assessed on an outpatient basis using the modified Rankin scale. The study primarily aimed to identify the factors predicting the severity and outcome of stroke, and to evaluate the effect of thrombolysis on the outcome. The secondary aim was to evaluate the role of biomarkers to predict the unfavorable outcome and the chance of post thrombolysis hemorrhage.Results: Out of 30 patients included in the study, 10 had NIHSS 0-4, 12 had NIHSS 5-15 and 8 had NIHSS 16-42. Sixteen patients had unfavorable outcome (mRS score ≥ 2), and 5 patients expired. Old age, history of diabetes, CHADS2 score ≥ 2, and total anterior circulation stroke (TACS) independently affected stroke severity, whereas low ejection fraction < 35%, and TACS, independently predicted unfavorable outcome and mortality. High mean arterial blood pressure (MABP) and capillary blood glucose (CBG) at admission were significant predictors of stroke severity, unfavorable outcome, and mortality. Out of 10 thrombolysed patients, two had mRS score ≥ 2 and 3 had the post-thrombolysis hemorrhage. Thrombolysis significantly reduced the incidence of the unfavorable outcome, but did not significantly affect death. All the biomarker levels at admission were significantly higher among patients with severe stroke and those who subsequently had an unfavorable outcome. D-dimer levels significantly increased and fibrinogen level significantly decreased following thrombolysis. Higher MABP, CBG, and fibrinogen levels at admission predicted significantly higher chance to develop hemorrhagic complications post thrombolysis.Conclusion: Low ejection fraction, occurrence of TACS and the higher levels of the biomarkers under study predicted poor outcome. Higher mean CBG and MABP and raised fibrinogen levels predicted higher chance of post-thrombolysis hemorrhage