الفهرس 
Acknowledgement
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Abstract
Electrolyte disturbances are commonly encountered in acute stroke setting, (Siddique et al, 2012) and may adversely affect outcome of acute stroke patients, (Sajadieh et al, 2009).
Aim of the study:
1. To estimate the relative frequency of electrolyte disturbances among patients with 1st ever acute CVS.
2. To assess the possible relationship of electrolyte disturbances to stroke severity and short-term outcome.
Study design:
It is prospective Descriptive study that extended from 1st of June till the end of November 2015.
Subjects:
All patients with the first ever CVS (whether ischemic or haemorrhagic) who attend the neurology inward department or stroke unit of Assiut university hospital within the first 48 hours of stroke were included in the study. A total of 331 patients (187 males and 144 females) were included.
Selection criteria of the Patients
Inclusions criteria:
1. Type of stroke: first ever stroke (either Ischemic or haemorrhagic stroke).
2. Age: any age groups
3. Sex: both sex are included in this study
4. First 48 hours of the CVS onset.
Exclusions criteria:
1. Patients on renal dialysis, or other organ failure.
2. Other neurological diseases other than stroke
3. Recurrent stroke.
Methods:
All Patients were subjected to the following:
1. History case taking, and assessment of Comorbid conditions :
• History of hypertension,
• DM,
• Myocardial infarction,
• Atrial fibrillation,
• Cancer,
• PreviousCVS is obtained using appendex I
2. History taking of pre-stroke therapies, with emphasis on :
• Anti-hypertensive (ACE inhibitor, angiotensin receptors blockers, beta-blockers, alpha sympatholytic),
• Anti-diabetics (insulin, oral hypoglycaemic),
• Antidepressant
• And antiepileptics
are recorded on admission.
3. Clinical and neuropsychiatric assessment using appendex I
4. Assessment of stroke severity by NIHSS on admission and every other day till 7th day or discharge. Appendex II
5. Estimation of serum metabolic profile including
• Na,
• K,
• Ionized Ca
• Ionized Mg
• Blood sugar,
• Urea,
• And Creatinine,
on admission and every other day along 1st week.
6. Evaluation of short-term outcome by:
• Mortality during hospitalization.
• Evolution of neurological status of survivors through difference between NIHSS score at discharge and score at admission
Results:
The present study show:
from the1st of June 2015 to 30th of November 2015, 331 patients were admitted to neurology department with 1st ever stroke, with mean age 56.2 ± 11.9, of whom 56.5% was males. The majority of patients had arterial ischemic stroke (63.1%). The most commonly affected artery was MCA (75.8%). Most of the patients (66.8%) had severe stroke (NIHSS>15), with mortality rate of the studied sample was 13.6% within their 1st week of stroke.
Dyskalemia was most commonly encountered electrolyte disturbance among acute CVS patients (25.7%), followed by dysnatremia (22.0%) especially hyponatremia and hypokalemia which was recorded in a similar rate (17.8%). However, towards the end of 1st week of stroke, dysnatremia (32.0%) particularly hyponatremia (28.8%) were recorded with the highest rate of electrolyte disturbancesfollowed by hypomagnesemia (17.1%).
Patients presented with sever CVS (NIHSS > 15) had the highest rates of dysnatremia, dyskalemia, dysmagnesemia, and dysglycemia.
Dysnatremia was recorded in a similar rate (22%) among patients with ischemic and hemorrhagic stroke, while dyskalemia, dyscalcemia, and dysmagnesemia were recorded with slightly higher rates among hemorrhagic stroke patients. On the other hand abnormal blood urea, creatinine, and blood sugar levels are slightly more common among cases with ischemic stroke.
CVS in the territory of PCA was associated with the highest rates of dyskalemia (29.3%), dyscalcemia (22.0%), dysmagnesemia (24.4%), dysglycemia (29.3%), together with highest rate of increased creatinine level (31.7%). On the other hand ACA stroke was associated with the highest rates of dysnatremia (30.3%), and increased blood urea (60.0%).
Diabetic stroke patients had higher rates of dysnatremia and dyskalemia, particularly hyperkalemia, than non-diabetics stroke patients (15.2%# 6.0%). Furthermore they had higher rates increased blood urea and creatinine than non-diabetics.Diabetic patients on insulin therapy had the highest rates of electrolytes disturbances, increased blood urea and creatinine, than those on oral hypoglycemic and non-diabetics CVS patients. Hypertensive patients with CVS had higher rates of dysnatremia (22.1% # 12.0%) and dysglycemia (27.4% #23.4%) than non-hypertensive CVS patients, Hypertensive patients on Ca- channel blockers had the highest rates of dysnatremia, while patients on ACE inhibitors had the highest rates of dyskalemia and dyscalcemia.On the other hand, those receiving B-blockers recorded the highest levels of hyperglycemia, and hypomagnesemia , while all patients kept on diuretics, had highest rates of increased blood urea (100%) and creatinine (37.5%).
Brain stem stroke was associated with the highest rates of all electrolyte disturbances and abnormal biochemical parameters.
Among survival of acute CVS, patients with electrolytes disturbance showed clinical deterioration. This was significant among cases with hyponatremia, hypernatremia, hypokalemia who were not amenable for correction. CVS patients presented with hypocalcemia and hypomagnesemia showed significant clinical deterioration despite correction of the concomitant electrolyte disturbance.The most commonly encountered electrolyte disturbance among cases that died of acute CVS within the 1st week was dysnatremia (40.0%), and of other biochemical parameters, increased blood urea (75.6%).
Conclusion:
• Electrolyte disturbance is a quite common problem after acute stroke and affects its prognosis.
• Dyskalemia(25.7%) and Dysnatremia (22.0%) is the most common electrolyte disturbances encountered in acute CVS patients.
• About one half (56.8%) of patients with acute CVS have increased blood urea, and about one fourth (23.0%) & (25.7%) had increased blood creatinine level and hyperglycemia respectively.
• Stroke in the distribution of posterior cerebral artery(brain stem stroke) have the highest rates of electrolyte disturbances(K+, Mg++, Ca++).While patients with severe stroke (NIHSS >15) have the highest rate of electrolyte disturbances.
• Diabeticstroke patients on insulin therapyhad the highest rate of electrolyte disturbances (Na+, K+, Mg++, Ca++) and increased blood urea and creatinine.
• Hypertensivestroke patients on B.blocker had highest rates of hypomagnesemia and hyperglycemia. Those on ACE inhibitors had highest rates of dyskalemia &dyscalcemia, while those on Ca-channel blockers had highest rates of dysnatremia.
• CVS patients with hyponatremia, hypernatremia, hypokalemia who were not amenable for correction show clinical deterioration.
• CVS patients presented with hypocalcemia and hypomagnesemia showed significant clinical deterioration despite correction of the concomitant electrolyte disturbance.
• Dysnatremia (40%) and increased blood urea(75%) are the commonest among cases who diedwithin the 1st week of stroke.
Recommendation
1. Serum electrolyte level should be determined andclosely monitored in every patient with acute stroke.
2. Fluid chart should be monitored with carful and prompt management of any electrolyte disturbances in acute CVS stroke.
3. Electrolyte disturbances are highly anticipated in Hypertensive patients, with posterior circulation stroke, and in Diabetic patientson insulin therapy. Those are in need for careful monitoring and early management.
4. Rapid and carful correction of hypomagnesemia in cases of SAH might prevent cerebral vasospasm and delayed cerebral ischemia.