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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 47  |  Issue : 2  |  Page : 45-51

Predictive variables of mortality after acute ischaemic stroke in Tanta University Hospital


Neuropsychiatry Department, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission12-Oct-2017
Date of Acceptance31-Oct-2018
Date of Web Publication18-May-2020

Correspondence Address:
MSc Ahmed M.M El-Husseiny
Neuropsychiatry Department, Faculty of Medicine, Tanta University, El-Gharbia, Tanta, 31512
Egypt
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DOI: 10.4103/tmj.tmj_75_17

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  Abstract 


Background Acute ischaemic stroke (IS) is a major cause of mortality and long-term morbidity.
Aim The aim of this study was to evaluate the predictors associated with increased mortality in acute IS.
Patients and methods This prospective study was conducted on 251 patients with acute IS admitted to the Department of Neuropsychiatry, Tanta University, over 6 months, and these patients were followed-up for another 6 months. Patients were divided into group I, which included 66 patients who died after acute IS, and group II, which included 185 patients who survived after acute IS. All patients were subjected to full history taking and general and neurological examinations; stroke severity was assessed by National Institute of Health Stroke Scale; type of stroke was determined by Oxfordshire Community Stroke Project Classification and Trial of Org 10172 in Acute Stroke Treatment classifications, ECG, routine laboratory investigations and brain imaging. Patients were followed-up by Modified Rankin Scale.
Results Patients in group I had a higher mean age (81.45±12.390). Diabetes mellitus and ischaemic heart disease were more prevalent in group I (68.2 and 90.9%, respectively). Coma was observed to be more in group I (37.88%). The mean of National Institute of Health Stroke Scale and Modified Rankin Scale was higher in group I (19.42±3.53 and ≥4, respectively). Total anterior circulation infarct and stroke of the large artery were more prevalent in group I (59 and 63.6%, respectively). Cerebral edema and leukoaraiosis were observed to be more in group I (87.9 and 80.3%, respectively).
Conclusion Early mortality after acute IS is usually due to neurological complications. Septic conditions are considered one of the major causes of post-IS death after the first month.

Keywords: ischaemic stroke, mortality, predictors


How to cite this article:
El-Husseiny AM, El-Heneedy YA, Fayed HA, Rahman WA. Predictive variables of mortality after acute ischaemic stroke in Tanta University Hospital. Tanta Med J 2019;47:45-51

How to cite this URL:
El-Husseiny AM, El-Heneedy YA, Fayed HA, Rahman WA. Predictive variables of mortality after acute ischaemic stroke in Tanta University Hospital. Tanta Med J [serial online] 2019 [cited 2020 Jun 6];47:45-51. Available from: http://www.tdj.eg.net/text.asp?2019/47/2/45/284499




  Introduction Top


Stroke has different emotional and socioeconomic consequences on humans, family, and society. Stroke is a leading cause of death and disability. Annually, about 16 million first-ever strokes occur in the world, causing a total of 5.7 million deaths. As a consequence, stroke ranks as the second cause of death in the world population after ischemic heart disease [1].

Ischaemic stroke (IS) is a major cause of long-term disability and mortality [2]. In 20–40% of patients with IS, neurological symptoms progress during the initial hours, leading to an increase in poststroke mortality [3].

A previous prospective study had identified risk factors for IS and stroke mortality, including advancing age, hypertension, diabetes, smoking and atrial fibrillation [4].

The identification of early mortality predictors after acute IS is very important for clinicians, so that specific therapies and management strategies can be applied to patients at high risk of dying. However, only limited information is available for predictors of mortality after acute IS [5].


  Aim Top


The aim of this study was to evaluate the important predictors associated with increased mortality rate in acute cerebral IS.


  Patients and methods Top


After obtaining the research ethics committee’s approval and after the written informed consent was taken from patients or their relatives, this prospective study was conducted on 294 patients with acute IS admitted to the Department of Neuropsychiatry, Tanta University, over 6 months, and these patients were followed up for another 6 months. This study was carried out from April 2015 to April 2016. The total number of patients at the end of the follow-up period was 251 patients, who were divided into group I, which included 66 patients who died after acute IS and group II, which included 185 patients who survived after acute IS. All patients were subjected to the following protocol:
  1. Full history taking.
  2. General and detailed neurological examinations.
  3. Assessment of level of consciousness of patients by the Glasgow Coma Scale.
  4. Assessment of stroke severity according to the National Institute of Health Stroke Scale (NIHSS) [6].
  5. Determination of type of stroke was carried out according to Oxfordshire Community Stroke Project Classification (OCSP) [7]. Acute IS was classified into four groups: lacunar infarcts, total anterior circulation infarcts (TACI), partial anterior circulation infarcts and posterior circulation infarct.
  6. Classification according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) [8]. Acute IS was classified into the following categories: atherosclerosis of a large artery, embolism of cardiac origin, occlusion of a small blood vessel, nonatherosclerotic vasculopathy, undetermined etiology and cryptogenic.
  7. ECG and routine laboratory investigations were performed for all patients.
  8. Brain imaging (computed tomography scan and/or MRI).


All patients were treated according to a standard treatment protocol used in the Stroke Unit at the Neuropsychiatry Department of Tanta University Hospital. Patients were followed up after 1 month (date 1), 3 months (date 2) and 6 months (date 3) to follow-up the death rate after stroke and to determine causes of death at each date by systemic and neurological examination according to the Modified Rankin Scale (MRS) [9], routine laboratory investigations and brain imaging according to the evaluation of the general and neurological condition of the patients.

Statistical analysis

The collected data were organized, tabulated and statistically analyzed using SPSS software statistical computer package version 16. For quantitative data, the range, mean, and SD were calculated. For qualitative data, the comparison between two groups was carried out using χ2-test. Significance was adopted at P value less than 0.05 for interpretation of results of tests of significance.


  Results Top


As regards age distribution, patients in group I had a higher mean age (81.45±12.390) than group II (58.72±10.429), with a significant statistical difference (P<0.001). On comparing sex distribution, in group I, there were 42.4% male individuals and 57.6% female individuals, whereas, in group II, there were 47.6% male individuals and 52.4% female individuals, with no significant statistical difference between the studied groups (P=0.450).

Diabetes mellitus and ischaemic heart disease (IHD) were observed in 68.2 and 90.9%, respectively, of group I and 6 and 22.8%, respectively, of group II, with a significant statistical value (P<0.001 and <0.001, respectively), considering them as risk factors for poststroke mortality, as shown in [Table 1].
Table 1 Major risk factors among the studied groups

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On comparing clinical findings, comatose patients were present in 37.88% of group I and 0% of group II with a significant statistical value (P<0.001), as shown in [Figure 1].
Figure 1 Causes of death among group I.

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On evaluation of stroke severity, the mean NIHSS score was 19.42±3.53 in group I and 12.24±1.93 in group II, with significant statistical difference (P<0.001), as shown in [Table 2].
Table 2 Stroke severity measured by National Institutes of Health Stroke Scale among the studied groups

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As regards stroke classification by OCSP, this study showed that TACI was present in 59% of group I and 4.3% of group II, with significant statistical difference (P<0.001), as shown in [Figure 2]. IS was classified by TOAST classification and showed that a stroke of large artery atherosclerosis was the most common type in group I (63.6%) compared with 10.8% of group II, with significant statistical difference (P<0.001), as shown in [Table 3].
Figure 2 Stroke classification according to OCSP (The Oxfordshire Communiy Stroke Project) among the studied groups.

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Table 3 Stroke classification according to Trial of Org 10172 in Acute Stroke Treatment classification among the studied groups

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This study showed that the middle cerebral artery (MCA) infarction was observed in 48.5% of group I and 5.4% of group II, with significant statistical difference (P<0.001). As regards other radiological findings, cerebral edema, midline shift and leukoaraiosis were present in 87.9, 59.1, and 80.3%, respectively, of group I and 5.4, 5.4, 17.4%, respectively, of group II with significant statistical difference (P<0.001, <0.001, and <0.001, respectively).

MRS was used in this study to follow-up patients and the mean score of MRS at dates 0, 1, 2, and 3 was higher in group I (5.045±1.07, 5.19±0.74, 5.61±0.49, and 6±0.23, respectively) compared with (2.336±0.80, 1.94±1.019, 1.55±1.14, and 1.19±1.051, respectively) in group II, with significant statistical difference (P<0.001, <0.001, <0.001, and <0.001, respectively), as shown in [Table 4].
Table 4 Follow-up of patients in the studied groups according to Modified Rankin Scale

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On further evaluation of different causes of death, it was found that at date 0, the cause of death was the initial stroke in all patients. At date 1, the most common cause of death was pneumonia (53.4%), at date 2, the most common cause of death was cardiac related (37.4%) followed by pneumonia (25%) and, at date 3, the most common cause of death was cardiac related (50%) followed by other infections such as bed sores and recurrent IS in 20%, as shown in [Figure 3].
Figure 3 Causes of death among group I.

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  Discussion Top


As regards the age distribution, patients in group I had a higher mean age than patients in group II, with a significant statistical difference, most probably due to poor collateral circulation in old age [10]. This is in accordance with the results of Mogensen et al. [11] who found that old age was an independent predictor of IS severity and poststroke morbidity and mortality.

There was no statistical difference between the two groups with regard to sex distribution. This is in concordance with Mogensen et al. [11] who did not consider sex as a risk factor for poststroke mortality.

As regards the risk factors, it was found that diabetes mellitus and IHD were more common in group I, with significant statistical value, as shown in [Table 1]. Most probably, this result was due to macrovascular complications of diabetes mellitus caused by atherosclerosis through several pathways [12]. In agreement with our results, Canoy et al. [13] considered IHD as an independent predictor factor of death after acute IS.

On comparing the clinical findings, coma was more observed in group I with significant statistical value, as shown in [Figure 1]. This is in accordance with the results of Khanal et al. [14] who considered that assessment of level of consciousness was very important in predicting the patient’s outcome after acute IS. He found that coma was more common among nonsurvivors than among survivors after acute IS.

As regards stroke severity measured by NIHSS, this study revealed that the mean NIHSS score was higher in group I than in group II, with a significant statistical difference, as shown in [Table 2]. In agreement with these results, Eskioglou et al. [15] considered that NIHSS was a good predictor of stroke outcome. NIHSS score of up to 6 predicted a good recovery, whereas a score of at least 16 was associated with a high probability of death or severe disability.

On comparing the stroke classification by OCSP, TACI was more observed in group I (59%) with a significant statistical difference, as shown in [Figure 2]. This is in concordance with Yang et al. [16] who observed that patients with TACI exhibited greater hemorrhagic transformations, higher mortality rate and worse 3-month clinical outcomes than patients with non-TACI. Most probably, this result was due to the large size of infarction and neurological complications such as cerebral edema, brain tissue shifting and increase in intracranial pressure, which occurred in the majority of TACI cases [17].

IS was etiologically classified according to TOAST classification. It was found that stroke of large artery atherosclerosis was more common in group I, with a significant statistical difference, as shown in [Table 3]. In agreement with these results, Kumar et al. [18] considered that stroke of large vessel disease is a great risk factor for early neurological deterioration, early poststroke mortality and poor functional outcome when compared with other stroke subtypes. This finding was usually due to impaired cerebral autoregulation and poor perfusion of an ischaemic brain caused by severe atherosclerosis of cerebral blood vessels [19].

As regards radiological findings in computed tomography and MRI among the studied groups, MCA infarction was observed to be more in group I with a significant statistical difference. This result was due to massive MCA infarction that led to brain edema and midline shift. Moreover, severe disability associated with MCA infarction played an important role in poststroke mortality [20]. With regard to other radiological findings, cerebral edema, midline shift, and leukoaraiosis were more observed in group I, with a significant statistical difference. In agreement with our results, Pipat et al. [21] found that 10% of subjects with an acute IS suffered from severe cerebral edaema leading to midline shift and brain herniation. They observed that the increased degree of midline shift in patients with stroke was related to the severity of IS and was significantly related to poor final clinical outcome.

It was found that the mean score of MRS at dates 0, 1, 2 and 3 was higher in group I, with significant statistical difference, as shown in [Table 4]. This is in concordance with Huybrechts et al. [22] who found that high MRS score (3–5) is a significant independent factor of mortality among cerebral ischemic stroke patients.

On further evaluation of the different causes of death among patients in group I, it was found that at date 0, the cause of death was initial stroke in all dead patients. This finding was usually due to severe neurological complications in acute stage, such as massive brain edema, brain herniation and haemorrhagic transformations, which were usually associated with massive brain infarctions [18]. At date 1, the most common cause of death was pneumonia, at date 2, the most common cause of death was cardiac related followed by pneumonia and, at date 3, the most common cause of death was cardiac related followed by other infections such as bed sores and recurrent IS, as shown in [Figure 3]. Canoy et al. [13] in a study performed on 62 patients who died within 3 months after acute IS considered that the causes of death after acute IS were as follows: the initial event was present in 69%, pneumonia was present in 19%, intracerebral haemorrhage was present in 15%, recurrent stroke was present in 10%, myocardial infarction in 3% and cancer was present in 1.5%.


  Conclusion Top


Older age, diabetes mellitus, and IHDs were found to be the major risk factors associated with increased mortality after acute IS. TACI and infarction of large artery atherosclerosis are usually associated with severe disability and poststroke mortality. Coma due to neurological complications of massive stroke such as midline shift and brain herniation are the major predictors for early mortality after acute IS. Severe chest infections are considered one of the major causes of post-IS death after the first month.

Acknowledgements

The authors thank all members of the Neuropsychiatry Department, Faculty of Medicine, Tanta University for their help and cooperation.

All authors contributed an equal role in design, work, statistical analysis, and manuscript writing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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