Glycated Hemoglobin Level is Significantly Associated with the Severity of Ischemic Stroke in Libyan Non Diabetic and Diabetic Patients

Stroke is a condition that results in high mortality rate and severe disabilities. Most stroke survivors can do experience improvements in their functional abilities, but the amount, rate, timing, pattern, type, and ultimate outcome of the improvements differ across patients and situation (Wolf CD, et al. 2000). Numerous studies were conducted on the prognostic factors of acute ischemic stroke. Stroke severity and patient age are the main predictors of stroke outcome in acute phase (Adams HP, et al. 1999; Frankle MR, et al. 2000; Muir KW, et al. 1996).


INTRODUCTION
Stroke is a condition that results in high mortality rate and severe disabilities. Most stroke survivors can do experience improvements in their functional abilities, but the amount, rate, timing, pattern, type, and ultimate outcome of the improvements differ across patients and situation (Wolf CD, et al. diabetic patients had worse residual neurological deficits and functional outcome when compared with non diabetic patients (Shindo A, et al. 2014; Cantu -Brito C, et al. 2010; Mankovsky BN, et al. 2004). Hyperglycemia occurred in up to one -third of patients with acute ischemic stroke was associated with higher mortalities independent of age and stroke severity (Luitse MJ, et al. 2012; Kruyt ND, et al. 2012).
Hemoglobin A1c has direct relationship with mean glycemia because erythrocytes are continuously glycated during their 120 -day lifespan, which means that the rate of formation of glycated hemoglobin, also called HbA1c, is proportional to the ambient glucose concentration (Saudek CD, et al. 2006). In the diabetes control and complication trial, an HbA1c of 6% corresponded to a mean serum glucose level of 135 mg/dl, and the measurement of HbA1c has been the primary index of glycemia (Saudek CD, et al. 2006). An HbA1c test can be used to diagnose pre-diabetes or diabetes and check the long term control of blood glucose levels in people with diabetes. Serum blood glucose level changes during the day for many reasons, including medicine, diet, exercise. And the level of insulin in the blood. While the HbA1c test result is not affected by any recent changes (American Diabetes Association. Standards of medical care in diabetes. 2014).
The aim of this study was to elucidate the association between glycemic control status, defined by HbA1c on admission and the severity of acute ischemic stroke in diabetic type II Libyan patients.

AIMS AND OBJECTIVES
To know the glycemic status by estimating the HbA1c, fasting and postprandial plasma glucose at admission among patients with acute ischemic stroke. To study the effect of HbA1c on the severity of acute ischemic stroke at admission in patients with diabetes type II and without diabetes. To compare the poor and good glycemic status patients among the diabetics for the competence of glycemic status on the severity of stroke.

PATIENTS AND METHODS
This is case control study of 40 patients admitted to hospital with diagnosis of acute ischemic stroke with diabetes as cases.
Cases (All acute ischemic stroke patients with diabetes) were categorized into 2 subgroup based on HbA1c level at time of admission as acute ischemi stroke patient with diabetes with good glycemic control (<7HbA1c) and acute ischemic stroke patients with poor glycemic control (>7HbA1c). 40 acute ischemic stroke patients without diabetes as control, were over age 39. Data were collected through interview case and controls, physical and neurological examination by study physicians.
The diagnosis of cerebral infarction was confirmed by Brain-CT scan. Echocardiography was done to exclude heart failure. ECG was done to exclude Atrial fibrillation.
Stroke severities were evaluated by using the National Institute of Health Stroke Scale (NIHSS) score on admission. The NIHSS is a tool used to objectively quantify the impairment caused by stroke and is composed of 11 items: level of consciousness, horizontal eye movement, visual field test, facial palsy. Motor arm, motor leg, limb ataxia, sensory, language, speech, extinction and inattention. Each of these specific abilities is given score between 0 and 4. For each item, a score of (0) indicates normal function, (1 -4) mild stroke, (5-15) moderate stroke (>15) sever stroke (National Institute of Health, Institute of Neurological Disorder and Stroke. Stroke Scale).
Glycemic status in acute ischemic stroke patients was evaluated by measuring the HbA1c, fasting and post prandial plasma glucose were recorded for all individual HbA1c level were recorded at time of stroke when patient initially admitted, FBG, PPG, BP and lipid profile values were taken from the data base of the registry of these patients, height and weight were measured and body mass index was calculated by dividing the weight (kg) by the height (m ²) The exclusion criteria were intracerebral hemorrhage, space occupying lesion, subarachnoid hemorrhage, cerebral venous thrombosis, transient ischemic attack, a trial fibrillation, acute myocardial infarction, heart failure, end stage renal failure.

Other Various Risk Factors
Bp measurement, cigarette smoking to be quantified based on daily consumption and duration of smoking. Blood biochemistry analysis was made; cholesterol, TG, LDL, HDL, CBC, RFT.

Statistical Analysis
Was performed by using SPPS software (version 11), difference among groups was analyzed by (t-test) and P value 0.05 was considered significant. There were no statistical significant associations between the two groups regarding glycemic indicators (FPG, PPG, HbA1c). Interesting finding to be noted was stroke severity are not different among the patients of good glycemic control group and nondiabetic group.

DISCUSSION
An increased HbA1c level reflects poor long term glycemic control and has its specific implications on the structure and function of vascular bed including small as large cerebral vessel. Increased HbA1c level might also be marker of poor compliance indicating an unhealthy life style. . In summary the current study suggests that blood HbA1c levels on admission may influenceseverity in patients with acute ischemic stroke. So, HbA1c level may be is an important predictors to evaluate the neurological impairment in patients of acute ischemic stroke with diabetes. Therefore, effectively lowering blood HbA1c levels may reduce the severity of neurological impairment in patients with acute ischemic stroke, and perhaps can improve the life quality of patient with ischemic stroke.

CONCLUSION
Among the diabetic stroke patients severity of glycemic status found to have an influencing effect on the stroke severity. Estimation of HbA1c levels at the time of admission might be a predictor of the severity of neurological impairment in patients with acute ischemic stroke. With achievement of near normal glycemic status in diabetic population the stroke severity can be brought to the same extent of observed in non diabetic population. We suggest the need for routine HbA1c testing in all patients with ischemic stroke for secondary