The current work was a case-comparison study. Sixty male and 40 female patients with acute CVS (within 1 week) who were admitted to stroke care monitoring unit and internal medicine department of Aswan University Hospital from July to December 2018 were included in the current study. Patients proved by CT (Siemens Spirit Dual Slice CT Scanner, Rs 54 Lakh, Germany) to have brain pathology other than stroke, refuse to participate, known to be diabetic, renal, hepatic, and those receiving medications that promote electrolyte disturbance “fluids, furosemide, corticosteroids, and thiazides” were excluded.
Patients were classified according to their clinical picture and investigations including CT (Siemens Spirit Dual Slice CT Scanner, Rs 54 Lakh, Germany) and/or MRI brain (Siemens Trio 3 T MRI Scanner, Rs 385 Lakh, Germany) into ischemic and hemorrhagic stroke (cerebral and subarachnoid hemorrhage).
Sample size calculation was carried out using G*Power 3 software . A calculated minimum sample of 98 stroke patients (raised to 100) divided into two groups (50 hemorrhagic and 50 ischemic) were needed to detect an effect size of 0.1 in the mean Glasgow Coma Scale (GCS), with an error probability of 0.05 and 90% power on a two-tailed test.
Data on self or family reported risk factors for stroke, including socio-demographics, hypertension, heart diseases, and smoking, were obtained from the patient’s medical records. Fasting blood glucose level was measured glucometer (Accu Check Advantage®, Roche, USA) after hospital admission, and increased glucose level was considered when fasting blood glucose level was > 110 mg/dl. Glycosylated hemoglobin (HbA1c) was measured by test kits (Eurolyser ®, Eurolyser Diagnostica GmbH, Bindergasse 3, Salzburg/Austria) to rule out undetected diabetic patients (normal value 4.5- < 6.5%, while HbA1c ≥ 6.5% means previously uncontrolled hyper glycemia). Stress hyperglycemia was labeled if fasting blood glucose > 110 mg/dl together with HbA1c < 6.5%, and undiagnosed diabetes was diagnosed when HbA1c ≥ 6.5% of blood sugar. Serum sodium (Na) was measured by MODULAR ANALYTICS E170® system (Roche Diagnostics, Indianapolis, IN) for all patients (normal Na = 135–145 mEq/L), where, Na > 145 mEq/L indicates hypernatremia , whereas Na < 135 mEq/L indicates hyponatremia . Also, serum potassium (K) was measured (normal K = 3.5–5 mEq/L), where, K > 5 mEq/L means hyperkalemia and K < 3.5 mEq/L means hypokalemia . A standard 12-leads electrocardiogram (ECG) and/or echocardiography were performed to all stroke patients to determine any arrhythmias and/or any ischemic changes (CON-TEC, model: ECG100G, China).
Initial assessment of CVS severity at time of admission and follow up-assessment after 1 week by GCS and the number of deaths if present were estimated. GCS is of prognestic value in acute CVS patients and is widely used in assessing level of consciousness , which may the mostly affected with stress hyperglycemia and electrolyte disturbance, while other scales such as the National Institutes Of Health Stroke Scale (NIHSS) evaluate the outcome of therapeutic management of CVS patients (not fessible to our patients due to many obstacles as, lack of finance, arrival after time window for stoke). Moreover, we used Barthel Index , but the results were insignificant. Generally, brain injury is classified as severe (GCS ≤ 8), moderate (GCS 9–12), and minor (GCS ≥ 13) .
Data were verified, coded by the researcher and analyzed using IBM-SPSS version-21 (@IBM-SPSS Inc., 2012, NY-USA) . Descriptive statistics means, standard deviations, and percentages were calculated. Test of significances chi-square test was used to compare the difference in distribution of frequencies among different groups. The clinical and demographic factors with proven statistical significance from the univariate analyses were further included in the multivariate logistic regression model. A p value equals or less than 0.05 was considered significant.
Approval for this study was obtained from the institutional review board (IRB) of Faculty of Medicine Aswan University prior to study execution. In addition, all participants’ caregivers received a written consent form. The informed consent was clear and indicated the purpose of the study, and their freedom to participate or withdraw at any time without any obligation. Furthermore, participants’ confidentiality and anonymity were assured by assigning each participant with a code number for the purpose of analysis only. The study was not based on any incentives or rewards for the participants.