Introduction
Stroke is the second leading causes of death worldwide and one of the leading causes of disability. The most common cause of stroke is represented by cerebral ischemia and approximately 80% of strokes are due to ischemic cerebral infarction and 20% due to brain haemorrhage.1 Diabetes Mellitus is a very common metabolic disorder and it is an independent risk factor for stroke and is associated with 2 to 6 fold increased risk compared with non-diabetic subjects and worsens survival of patients with acute stroke.
Approximately 20% of patients with Diabetes die from stroke. (2)Stroke is more commonly seen in Males when compared to females.2, 3 The mechanism is believed to be accelerated atherosclerosis, which can affect vessels in many distributions, including small and large vessels.4
“According with TOAST classification is possible to distinguish various subtypes of ischemic stroke: 1) Large Artery Atherosclerosis (LAAS); 2) Cardioembolic Infarct (CEI); 3) Lacunar Infarct (LAC); 4) Stroke of other Determined Aetiology (ODE); 5) Stroke of Undetermined Aetiology (UDE).5 ”Gertler and his colleagues in a population with thrombotic stroke, found overt diabetes in 30% and abnormal glucose tolerance (Fajans and Conn criteria) in 59% of the rest. 6, 7
Glucose intolerance or even fasting hyperglycemia may follow an acute vascular event, and ensuing physical inactivity and poor food intake may lead to continued glucose intolerance. Thus, glucose intolerance in a stroke patient may or may not reflect glycemia prior to the event. Measurement of HbA1C rather than glucose as an indicator of prior glycemia offers a new perspective. The rate of non-enzymic glycosylation of hemoglobin is believed to depend largely or solely on plasma glucose concentration.8 Since the erythrocyte survives about 3 months, HbA1C measurements in patients with normal erythrocyte survival reflect plasma glucose concentrations during that period.
Hence this study is to evaluate the clinical profile of acute ischemic stroke in type 2 Diabetes Mellitus.
Aims and Objectives
To evaluate the clinical profile of acute ischemic stroke in type 2 Diabetes Mellitus.
Materials and Methods
Source of data
The information for the study will be collected from Patients with Acute Ischemic Stroke admitted to BLDEU’S SHRI B. M. PATIL MEDICAL COLLEGE HOSPITAL and RESEARCH CENTRE VIJAYAPUR between December 2016 to June 2018.
Method of collection of data (including sampling procedure if any):
Type of study - Cross sectional study.
With the proportion of stroke 50% at 95%confidence interval & 5%precesion calculated sample size is 64.
It is known that Ischemic stroke accounts for 80%of the Stroke.(67)
n = Z2 *p *(1-p) e2 Z - Z value at 95% Confidence interval. P - proportion rate. E - margin of error.
Hence 64 Ischemic stroke cases will be included in the study.
Study design
Estimation of Random blood glucose and HbA1c levels were done at the time of admission.
Patients were scored severity based on NIH stroke scale at the time of admission
Hba1c levels <6% indicates well controlled,6-9% indicates fairly controlled,>9% indicates poorly controlled
Infarct size on CT/MRI scan brain <3cm2 is small,3-5cm2 is moderate and >5cm2 is large infarct.
NIHSS score 0-4 indicates minor stroke, 5-15 indicates mild to moderate, 16-20 indicates severe and 21-42 indicates very severe neurologic impairment.
Results
Table 1
Distribution of patients according to Age (Years)
|
Age (Years) |
No. of patients |
Percentage |
|
< 40 |
1 |
1.6 |
|
40 – 49 |
8 |
12.5 |
|
50 – 59 |
12 |
18.8 |
|
60 – 69 |
22 |
34.4 |
|
70 – 79 |
13 |
20.3 |
|
80+ |
8 |
12.5 |
|
Total |
64 |
100.0 |
Table 2
Distribution of patients according to Gender
|
Gender |
No. of patients |
Percentage |
|
Male |
37 |
57.8 |
|
Female |
27 |
42.2 |
|
Total |
64 |
100.0 |
Table 3
Diabetic status in the study group n=64
|
HbA1C |
No. of patients |
Percentage |
|
< 6.00 |
25 |
39.1 |
|
6.00 - 9.00 |
16 |
25.0 |
|
9.0+ |
23 |
35.9 |
|
Total |
64 |
100.0 |
Table 4
Risk factors in our study group
|
Risk Factors |
No. of patients |
Percentage |
|
T2DM |
13 |
20.3 |
|
T2DM,SM |
15 |
23.4 |
|
T2DM,HTN,SM |
3 |
4.7 |
|
T2DM,HTN,DYS |
5 |
7.9 |
|
T2DM,HTN |
18 |
28.2 |
|
T2DM,DYS |
7 |
10.8 |
|
T2DM,RHD |
2 |
3.1 |
|
T2DM,RVD |
1 |
1.6 |
|
Total |
64 |
100.0 |
Table 5
Clinical Presentations in the study group
|
Motor Deficits |
No. of patients |
Percentage |
|
Present |
64 |
100 |
|
Total |
64 |
100.0 |
Table 6
Sensory Deficit presentations
|
Sensory Deficits |
No. of patients |
Percentage |
|
Present |
17 |
26.6 |
|
Absent |
47 |
73.4 |
|
Total |
64 |
100.0 |
Table 7
Distribution of Altered Sensorium
|
Altered Senosorium |
No. of patients |
Percentage |
|
Present |
19 |
29.7 |
|
Absent |
45 |
70.3 |
|
Total |
64 |
100.0 |
Table 8
Distribution of cranial nerve involvement
|
Cranial Nerve Involvement |
No. of patients |
Percentage |
|
Present |
35 |
54.7 |
|
Absent |
29 |
45.3 |
|
Total |
64 |
100.0 |
Table 9
Distribution of language Disturbance
|
Language Disturbance |
No. of patients |
Percentage |
|
Present |
29 |
45.3 |
|
Absent |
35 |
54.7 |
|
Total |
64 |
100.0 |
Table 10
Severity of the stroke
|
Severity |
Score |
No. of patients |
Percentage |
|
Minor stroke |
0-4 |
0 |
0 |
|
Moderate Stroke |
5-15 |
24 |
37.5 |
|
Moderate to Severe |
16-20 |
14 |
21.9 |
|
Severe Stroke |
21-42 |
26 |
40.6 |
|
Total |
|
64 |
100.0 |
Table 11
Descriptive Statistics
|
X |
Minimum |
Maximum |
Mean |
Std. Deviation |
|
AGE |
35 |
90 |
63.59 |
12.558 |
|
NIHSS score |
8 |
35 |
19.55 |
7.719 |
|
BLOOD glucose on admission |
80 |
420 |
212.23 |
88.907 |
|
HbA1C |
4.50 |
12.80 |
7.6766 |
2.27594 |
In this study well controlled Diabetes has moderate stroke severity, fairly controlled Diabetes has moderate to severe stroke severity and poorly controlled Diabetes has severe stroke. It is observed that severity of the presenting complaints worsened from well controlled Diabetes to poorly controlled Diabetes. The NIHSS score correlates with the HbA1C, with increase in severity of the stroke from well controlled Diabetes to poorly controlled Diabetes.
Summary
This is an cross sectional study including 64 patients.
Maximum number of patients were in the age group of 60 – 69 years, with mean age of 63.59±12.59 years.
The male to female of 1.37 : 1.
There were 25 patients (39.1%) well controlled Diabetes patients,16(25.0%) fairly controlled and 23 (35.9%)were poorly controlled Diabetic patients.
The common risk factors were Diabetes mellitus, hypertension, smoking, dyslipidemia, Rheumatic heart disease and Retroviral disease.
Commonest clinical presentation was motor weakness.
Others were cranial nerve dysfunction, altered. sensorium, language disturbances, sensory impairment. The severity of the presenting complaints worsened from well controlled diabetes to poorly controlled diabetes.
Conclusion
Commonest clinical presentation was motor weakness (100%)
Others were cranial nerve dysfunction (45.3%), altered sensorium (29.7%), language disturbances (45.3%), sensory impairment (26.6%). The severity of the presenting complaints worsened from well controlled diabetes to poorly controlled diabetes.
Patients with poorly controlled diabetes were found to have increased severity of stroke.Severity of the stroke worsened from well controlled diabetes to poorly controlled diabetes.
Article
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