This is a cross-sectional study that was done in the period from April 2015 to March 2017. All patients meeting the inclusion criteria of this study and admitted in the stroke units of Neurology, and Internal Medicine departments in Zagazig University Hospitals, Sharkia Governorate, Egypt, during this period were included in the study. Five patients died within 3 days after admission out of 505 patients, so only 500 were included in the study, and the patient’s age (mean ± SD/years) was 67.3 ± 10.2. Fifty-one out of 500 complicated with pneumonia, those patients were classified as group 1 (37 of them were males and 14 were females), and 449 were not complicated with pneumonia, those patients were classified as group 2 (68% of them were males and 32% were females).
Ethical consideration
A written consent was taken from all of the participants or their relatives after explaining the details of the study to them. The study was approved by the Institutional Ethical Committee of Faculty of Medicine, Zagazig University, Egypt (ZU-IRB#4728\24-3-2017).
Inclusion criteria
Patients were eligible for inclusion in the study if they had evidence suggesting the following:
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Acute ischemic stroke. Stroke was diagnosed clinically (as there was a new onset of neurological deficits that is corresponding to a vascular origin in the brain and lasted for more than 24 h) and proved via brain imaging (computed tomography with or without magnetic resonance imaging) (Chen et al. 2013).
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Pneumonia following acute ischemic stroke during the same hospitalization. Pneumonia was diagnosed if the acute ischemic stroke patient had relevant clinical manifestations (fever, new or increased cough, purulent tracheal secretion, or leukocytosis), positive microbiologic findings (blood, sputum cultures), and new onset of pulmonary infiltrates on chest radiography (Mirsaeidi et al. 2010).
Exclusion criteria
Patients were excluded from the study if they had comorbid medical illnesses likely to interfere with platelet function or morphology, e.g., chronic kidney disease, chronic liver diseases, and leukemia.
All patients were subjected to the following:
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Full history taking
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Thorough general and neurological examination
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Laboratory investigation
Complete blood count (CBC), using automated cell counter “model XS 500i (Sysmex, Japan),” together with examination of Leishman stained peripheral blood smears for differential leukocytic count. Mean platelet volume to platelet count ratio (MPV/PC) was calculated. MPV/PC ratio was considered increased if it is more than 0.031 according to Elsayed and Mohamed, 2016 (Elsayed and Mohamed 2017). Significant leukopenia and leukocytosis were defined as white blood cell (WBC) counts of, ≤ 4000 and ≥ 25,000, respectively. Thrombocytopenia and thrombocytosis were defined as platelet counts, ≤ 100,000/L or ≥ 400,000/L, respectively.
-Liver and kidney functions using automated analyzer “Cobas 501” (Roche diagnostics, Switzerland).
-C-reactive protein (CRP) and arterial blood gas analysis.
Alteration of gas exchange was defined as PaO2 < 60 mmHg or O2 saturation < 90% (Mirsaeidi et al. 2010; Katz et al. 2011).
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Imaging to confirm the presence of acute ischemic stroke and pneumonia: brain imaging (brain computed tomography with or without magnetic resonance imaging) and chest plain X-ray.
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Scales for assessment of patients included in the study:
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Neurologic status was assessed by the Glasgow Coma Scale (GCS) on admission and on pneumonia occurrence (Teasdale and Jennett 1974). It can be elicited via assessment of eye opening, motor response, and verbal response. Total score ranged from 3 to 15.
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The clinical severity of stroke was assessed on the day of admission using the National Institutes of Health stroke scale (NIHSS) (Lyden et al. 2001). The NIHSS is a well-validated and commonly used stroke impairment scale that is used to evaluate the level of consciousness, language, speech, extraocular movements, visual field loss, motor strength, sensory function, coordination, and hemi-neglect. We rated the patient’s ability to answer questions and perform activities. Ratings for each item are scored with 3 to 5 grades with 0 as normal. Patients were classified according to the NIHSS score into three groups: mild stroke, when the NIHSS score was ≤ 8; moderate stroke when the NIHSS score was from 9 to 15; and severe stroke when the NIHSS score was ≥ 16.
Statistical analysis
Descriptive statistical methods were used to calculate means and standard deviation (SD). For comparisons with the continuous variables, Student’s t test and ANOVA were used. Comparison of categorical data was performed using the χ2 test and the Fisher exact test. Multivariate and multiple regression analyses were used. Statistical significance was made at p value < 0.05. Data were analyzed using statistical package of social science, version 14 software package (SPSS Inc., Chicago, IL, USA) (Levesque 2007).