1

Acute Ischemic Stroke and Abnormal

Blood Hemoglobin Concentration

Balinda

Supervised By:
Dr. Selly Marisdina, Sp.S MARS
INTRODUCTION 2

Stroke Leading cause

Acute Ischemic Stroke
of mortality and
 Risk Factors
neurological disability.

The Implications of an
Few prior study  abnormal Hemoglobin
acute cerebrovascular in prevention and
event  abnormal management of acute
blood Hemoglobin ischemic stroke remain
uncertain.
Prior Studies 3

Tsai et al. • Association between acute cerebral infarction

and anemia in patients following marked blood
2010 loss without systemic hypotension

Chang et al • Diagnosed iron-deficiency anemia were at a

higher risk for acute ischemic stroke even after
2013 controlling for several confounders

Holme et al • Individuals with increased HGB were at higher risk

of ischemic stroke in a large cohort of individuals
2012 who mainly reside in the greater Stockholm area
INTRODUCTION 4

 Clinical Question:
Whether abnormally low or high HGB are
associated with
 More severe neurological deficit on
admission
 Greater degrees of disability at discharge
 7 day, 30 day, and 90 day mortality
 Length of Stay
MATERIAL AND METHODS 5

•RETROSPECTIVE COHORT STUDY

METHODS •11 DESIGNATED STROKE
HOSPITAL IN ONTARIO

•ALL PATIENT WITH ACUTE

SUBJECTS ISCHEMIC STROKE
•JULY 1, 2003-MARCH 31, 2008
MATERIAL AND METHODS 6

EXCLUSION
Intracerebral
Hemorrhage, Taking
Cerebral Venous Anticonvulsants and
subarachnoid
Thrombosis Iron supplement
Hemorrhage, Non
Stroke Patients

Patient with cancer,

renal failure, history
of gastrointestinal or Pregnant
genitourinary
bleeding
METHODS 7

All data analyses were adjusted for major potential confounders including
1. length of stay in the acute stroke care hospital
2. age,
3. sex,
4. ethnicity,
5. smoking status (i.e., current smoker or no),
6. alcohol consumption (i.e., rare, less than 2 drinks day, or more than 2
drinks a day),
7. thrombolytic treatment with tissue plasminogen activator (tPA),
8. stroke unit admission,
9. timing from stroke onset to the emergency department arrival,
10. and history of prior preexisting medical co-morbidities
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Low-HGB Normal-HGB
subgroup subgroup
(HGB < 14 • (HGB = 14–18
g/dl for men; g/dl for men;
HGB = 12–16
HGB < 12 g/dl g/dl for women)
HBG used for this study for women),
was from the initial blood
drawn on arrival to
emergency department,
and this was within 24 h High-HGB subgroup
• (HGB > 18 g/dl for
men; HGB > 16
g/dl for women)
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DISCUSSION 14

IN THIS STUDY:
Low and High hemoglobin concentrations at the
time of hospital admission are associated with
worse outcomes in patients with acute ischemic
stroke.
DISCUSSION 15

Low Hemoglobin
Significantly Increased
longer hospital 90-day mortality
stays in acute following acute
care ischemic stroke
Anemia, stroke severity, and outcomes after
acute ischemic stroke 16
Huang et al.
(982 ischemic stroke ) •Patients with anemia on admission (defined as a HGB < 12
2009 g/dl in women and <13 g/dl in men) had increased mortality
within the first 3 years

Del Fabbro et al
•Anemia on admission (defined as a HGB < 12 g/dl in women
(890 ischemic and hemorrhagic stroke)
and <13 g/dl in men) was independently associated with
2010 higher mortality within the first year after stroke

Kelller et al
(217 ischemic stroke)
•Poor outcome (defined as a modified Rankin Scale score from
3 to 6) and mortality at 3 months after stroke
2011

Sico et al
(1306 ischemic stroke ) •Anemia on admission (defined as an admission hematocrit
2013 value <30%) was ssociated with in-hospital mortality or
discharge to hospice among patients with less severe stroke

Gottesman et al
(203 acute right hemispheric ischemic) •Low HGB on admission more often had neglect, which were
2010 also more severe, than patients with normal HGB
DISCUSSION 17

High Hemoglobin
Significantly Predicted an
More severe
greater increased
neurological
degree of 7-day, 30-day,
impairment
disability at and 90-day
on admission
discharge. mortality
High HGB, stroke severity, and outcomes
18
after acute ischemic stroke

Tanne et al. • Increased mortality at 1 month and 1

year

Gottesman et al • On admission more often developed

neglect

Allport et al. • Elevated hematocrit on admission was

(MRI parameter) associated with reduced reperfusion
and tissue survival
Predicting outcomes based on the initial 19
blood hemoglobin concentration

 This is the first study to establish the optimal cut-

off values of HGB that are associated with the
greater mortality rates at 90 days following
acute ischemic stroke.
 According to our results, a HGB greater than 136
g/dl for men (or greater than 125 g/dl for
women) on admission could be used for the
prediction of 90- day mortality following acute
ischemic stroke.
Study strengths and limitations
A large prospectively accrued cohort of
individuals with acute ischemic stroke where
demographic and Clinical data were
collected.
The estimation of optimal cut-off values for
the prediction of 90-day mortality using the
ROC analyses
20
Some of the subjects in the study cohort could
have other preexisting medical co-morbidities
The study might have included individuals who
received treatment for abnormal HGB that
could affect their survival after stroke
Individuals with anemia could have other
hematological disorders
The sensitivity and specificity for the HGB
values are a limiting factor for their widespread
use in the clinical practice
CONCLUSION 21

 The results of our study indicate that low and high HGB on
admission are associated with worsen prognosis after an
acute ischemic stroke.

 Those findings underline the need for further Investigations

to elucidate the causes of the greater mortality among
patients with anemia or elevated HGB on admission after
acute ischemic stroke.
VIA 22

VALIDITY
Background:
Acute ischemic stroke has been
IMPORTANCE
associated with several risk factors .
Main Problem:
A few prior studies have suggested that
For clinical and research investigations
that specifically intend to
assess prognostic value.
APPLICABILITY
acute cerebrovascular events may be
associated with abnormal blood Applicable.
hemoglobin levels (HGB), either low or
high.
Aims:
This study examines whether low or high
blood hemoglobin concentration (HGB)
is associated with stroke severity, worse
clinical outcomes, and poorer prognosis
after acute ischemic stroke (AIS)

Clear Design, Method, and Result.

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TERIMA
KASIH