Impact of hemoglobin levels on acute ischemic stroke severity

 

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Impact of hemoglobin levels on acute ischemic stroke severity

Shaima Abuhulayqah¹Fajar Abdulrazzak Aldulijan²Alaa Nabil Turkistani³Albatoul Fahad Almulhim⁴Cereen Fahad Almulhim⁵Shahid Bashir^6,7Eman Nassim Ali^7,8*

• ¹Department of Adult Neurology, King Fahad Hofuf Hospital, Hofuf, Saudi Arabia
• ²Department of Family Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
• ³Neurosciences, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
• ⁴Department Neurology, King Fahad Medical City, Riyadh, Saudi Arabia
• ⁵Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
• ⁶Neuroscience Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
• ⁷King Salman Center for Disability Research, Riyadh, Saudi Arabia
• ⁸Department of Adult Neurology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

Introduction: Stroke is one of the most common causes of disability and mortality worldwide. In Saudi Arabia, it is a crucial health issue. Ischemic stroke is the most common type of stroke in this area, and understanding its relationship with hemoglobin (Hgb) levels is vital. To date, no study has established an exact relationship between Hgb levels and stroke severity. This study assessed the association between Hgb levels and the severity of acute ischemic stroke (AIS) at presentation.

Methods: We conducted a retrospective study of patients admitted and diagnosed with AIS between 2013 and 2017. The exclusion criteria included other stroke types (such as hemorrhagic or venous infarction), patients with a history of internal bleeding, and pregnant and lactating women. The patients were divided into three groups based on Hgb levels: low, average, and high. Correlations were analyzed between these groups and the National Institutes of Health Stroke Scale (NIHSS) scores, stroke outcomes at discharge (cured, improved, or mortality decreased), and stroke subtype, as determined and classified by the TOAST classification criteria.

Results: The Pearson correlation coefficient showed a weak positive correlation between Hgb levels and NIHSS scores. Neither stroke outcomes nor stroke types showed significant correlations with mean Hgb level.

Conclusion: The results of this retrospective study on a small cohort of patients diagnosed with AIS indicate that higher Hgb levels at hospital admission are associated with greater stroke severity, as measured by the NIHSS score. However, no significant effect was observed on stroke outcome at discharge or the TOAST classification.

Introduction

Stroke is one of the leading causes of disability and mortality worldwide. According to the World Health Organization (WHO), approximately 15 million people worldwide experience a stroke each year, with 5.5 million deaths and another 5 million living with enduring disabilities (1). Previous studies have described a U-shaped relationship between hemoglobin (Hgb) levels and short-term stroke mortality (2–4). Patients with low Hgb levels had higher mortality rates at all-time points compared to those with healthy Hgb levels. At the same time, high Hgb levels were also associated with elevated mortality rates. However, these studies did not account for different stroke types, which may have acted as confounding factors (5, 6).

Studies have shown that patients with anemia on admission have a higher risk of mortality within the first 3 years after stroke than those with healthy Hgb levels (3, 7, 8). Another study showed that among ischemic stroke survivors, a high Hgb level on admission was associated with more severe stroke, more significant disability at discharge, and higher 30-day mortality; however, a low Hgb level was not significantly associated with neurological impairment but was associated with higher 90-day mortality following a more extended period of stay in an acute stroke care facility (9).

Hgb is the essential structure for oxygen transport in red blood cells (RBCs) and helps maintain a stationary balance between oxygen supply and demand in all body tissues. Because a mismatch between oxygen supply and demand is the mainstay of the pathophysiology of acute ischemic stroke (AIS), identifying the factors contributing to this imbalance is essential. The pathophysiological pathways through which low and high Hgb levels affect stroke presentation and outcomes remain unclear (2–4, 10). Some investigators have hypothesized that low Hgb levels may induce hypoxia, while high Hgb levels may increase blood viscosity, leading to diminished cerebral blood flow (4).

In Saudi Arabia, stroke has become one of the most significant health concerns (11, 12). Although the incidence and prevalence of stroke in KSA are lower compared to other countries in the region (13), risk factors such as systemic hypertension (38%), diabetes mellitus (37%), and heart disease are highly prevalent (14, 15).

Because ischemic stroke is the most common type of stroke in this region, understanding the relationship between Hgb levels and this type of stroke is essential (13). Therefore, this study aimed to determine the relationship between Hgb levels and the severity of acute ischemic stroke at presentation.

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