Blood counts and homocysteine in acute stroke: What is the relation?

Debabrata Chakraborty; Pradipta Bhattacharjee; Sadanand Dey; Sanjay Bhaumik; Aditya Choudhary; Kishalaya Karan; Priyanjita Sen; Mohuya Mukherjee; Gobinda Pramanick; Nirmalya Ray; Anupam Chakrapani; Satya Narayan Singh; Binod Kumar Singhania; Biswajit Sengupta; Kajal Das; Aditya Mantry; Bhaskar Ukil; Rahul Ghosh

doi:10.4103/jopcs.jopcs_21_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 4 | Issue : 1 | Page : 3-9

Blood counts and homocysteine in acute stroke: What is the relation?

Debabrata Chakraborty¹, Pradipta Bhattacharjee¹, Sadanand Dey¹, Sanjay Bhaumik¹, Aditya Choudhary¹, Kishalaya Karan¹, Priyanjita Sen¹, Mohuya Mukherjee¹, Gobinda Pramanick², Nirmalya Ray², Anupam Chakrapani³, Satya Narayan Singh⁴, Binod Kumar Singhania⁴, Biswajit Sengupta⁴, Kajal Das⁴, Aditya Mantry⁴, Bhaskar Ukil⁴, Rahul Ghosh⁴
¹ Department of Neurology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
² Department of Radiology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
³ Department of Haematology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
⁴ Department of Neurosurgery, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India

Date of Submission	19-Jul-2022
Date of Decision	11-Oct-2022
Date of Acceptance	23-Oct-2022
Date of Web Publication	03-Jan-2023

Correspondence Address:
Dr. Debabrata Chakraborty
64/4A/9, Beliaghata Main Road, Kolkata - 700 010, West Bengal
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jopcs.jopcs_21_22

Abstract

Objectives: Stroke is the second-leading cause of death and the third-leading cause of death and disability combined in the world. We need to find easy, available, and reliable parameters on which we can depend to prevent stroke, predict outcome, and determine prognosis. This will help in stroke management in the future. Materials and Methods: We noted blood counts and serum homocysteine levels in acute stroke patients after the exclusion of confounding factors. Our team recorded the detailed demographic and blood parameters (blood counts and homocysteine) of acute stroke patients who got admitted to different departments of our hospital in 5 months. We later correlated or tried to find the association between these parameters and stroke severity (NIHSS), other clinical parameters such as dysarthria and stroke outcome (Modified Rankin Score (mRS) at discharge and at 3 months). The team also tried to find relationships, if any, with different stroke subtypes as per the Trial of ORG 10172 in Acute Stroke Treatment classification. Results: Out of 100 patients (34 females and 66 males), we had 28 patients with hyperhomocysteinemia (HHcy). The high neutrophil count and total leukocyte count correlated with stroke severity, dysarthria, and outcome at 3 months (poor mRS). While, it was the opposite in the case of lymphocyte count. Homocysteine level did not correlate with stroke severity or outcome but with dyslipidemia. HHcy was more prevalent among patients with large artery atherosclerotic disease. Conclusion: Findings of our study were agreeable to earlier studies on the relationship between blood counts and stroke prognosis. Although high homocysteine level was associated with stroke, its level was not found to be related to stroke severity or outcome. However, further study with a larger sample size is required to draw a confident conclusion.

Keywords: Acute stroke, blood counts, homocysteine

How to cite this article:
Chakraborty D, Bhattacharjee P, Dey S, Bhaumik S, Choudhary A, Karan K, Sen P, Mukherjee M, Pramanick G, Ray N, Chakrapani A, Singh SN, Singhania BK, Sengupta B, Das K, Mantry A, Ukil B, Ghosh R. Blood counts and homocysteine in acute stroke: What is the relation?. J Prim Care Spec 2023;4:3-9

How to cite this URL:
Chakraborty D, Bhattacharjee P, Dey S, Bhaumik S, Choudhary A, Karan K, Sen P, Mukherjee M, Pramanick G, Ray N, Chakrapani A, Singh SN, Singhania BK, Sengupta B, Das K, Mantry A, Ukil B, Ghosh R. Blood counts and homocysteine in acute stroke: What is the relation?. J Prim Care Spec [serial online] 2023 [cited 2023 Jun 6];4:3-9. Available from: https://www.jpcsonline.org/text.asp?2023/4/1/3/366811

Introduction

Stroke is the second-leading cause of death and the third-leading cause of death and disability combined in the world.^[1] Hence, we need to give our utmost effort to detect any preventable cause and find out parameters that may correlate with the outcome and prognosis of stroke. This will help in improving stroke management in the future.

In earlier studies, few blood parameters were availed to determine stroke severity and outcome in several parts of the world. This process may help us predict outcomes beforehand and hence plan treatment modalities accordingly. The investigations should be cost-effective and easily available.

Homocysteine is related to ischemic stroke.^[2] Low Vitamin B12 concentration contributes to almost 28% of patients with hyperhomocysteinemia (HHcy), while low folate concentration contributes to approximately 2% of patients with HHcy.^[3] White blood cell count is an independent predictor of stroke outcomes.^[4]

Hence, our plan was to find the relationship between different parameters of acute stroke with serum homocysteine, Vitamin B12, and blood counts. Next, we need to modify these modifiable factors so that the outcome may be converted to a favorable side.

Materials and Methods

We included acute ischemic stroke patients of 18 years and above who came to our institute and got admitted to the neurology, neurosurgery, and medicine department in 5 months (October 2021–March 2022). Our team noted the detailed demographics of the patient (including age, sex, and risk factors such as hypertension, diabetes, dyslipidemia, smoking, and alcohol consumption). We noted the standard scales: NIH stroke scale/score National Institutes of Health Stroke Scale (NIHSS) during admission and discharge. Our team noted other clinical parameters, such as dysarthria, aphasia, and dysphagia gugging swallowing screen (GUSS scores).

The team recorded mRS at baseline, discharge from the hospital and at 3 months. We collected superficial venous blood for measurement of homocysteine (Hcy) level. The chemiluminescence assay method assessed serum Hcy in one morning after the hospital admission with ischemic stroke with at least 8 h of fasting. We defined HHcy levels higher than 15 mmol/l as high homocysteine in the study.^[5] The team tested blood parameters: complete blood count, differential count, serum Vitamin B12 level, liver function test, renal function tests, fasting lipid profile, blood sugar parameters (fasting blood sugar, postprandial, and hemoglobin A1c), and thyroid function test.

We tried to exclude other associative factors which might act as a confounding factors in reaching our target. The team deliberately drew blood for Hcy 2–3 days after the ictus so that the acute inflammatory reaction causing HHcy (immediately post stroke) did not influence its level. Conditions associated with leukocytoses, such as infection (evident in the 1^st week of stroke) and hematologic malignancies. Systemic diseases: including chronic heart disease, neoplasm, uremia, autoimmune disease, liver disease, severe renal dysfunction, and chronic lung disease (that may affect total leukocyte count), were excluded.

The team categorized the ischemic stroke patients as per the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. We finally tried to correlate or tried to find associations between homocysteine level, Vitamin B12 level, blood counts (complete blood count, neutrophil count, lymphocyte count, monocyte count, hemoglobin, and platelet count) on one side; different demographic parameters, clinical parameters (NIHSS, MRS during admission, discharge and for 3 months, aphasia, GUSS score) on the other side.

Statistics

Continuous variables were expressed as mean ± standard deviation or median (Min–Max) and compared using paired t-test or Mann–Whitney U test (considering whether the data are following normal distribution or not). Categorical variables were expressed as number of patients and percentage of patients and compared using Pearson's Chi-square test for Independence of Attributes/Fisher's exact test as appropriate. Spearman's correlation was used to find any correlation between the parameters when the data did not follow the normal distribution. P < 0.05 was considered statistically significant in each case. Collected data were analyzed using MS Excel and SPSS 20.0 (IBM, Armonk, New York, USA.).

Results

There were 34 females and 66 males of acute stroke in our study time period who met the inclusion criteria. Twenty-eight number of patients had HHcY (10 females and 18 males). Thirteen patients (four females and nine males) had low Vitamin B12 concentration. Eighty-six patients had hypertension, while 14 patients were normotensive. Among 100 patients, 71 patients were diabetic, the rest were nondiabetic. Six were pure vegetarians, the rest 96 were on vegetarians. Four patients were dyslipidemic.

The neutrophil count at the hospital was positively correlated with NIHSS at admission, NIHSS at discharge, MRS at 3 months, and negatively correlated with the GUSS score. Total leukocyte count was negatively correlated with the GUSS score.

Severe stroke was associated with increased NIHSS, high MRS, and low GUSS score. The lymphocyte count was noted to be negatively correlated with NIHSS at admission, NIHSS at discharge, MRS at admission, at discharge, and at 3 months.

The Vitamin B12 level and hemoglobin level were noted to be positively correlated with mRS at admission (unique observation). Vitamin B12 and mRS at 3 months (higher Vitamin B12 was associated with higher mRS); a new observation. Hemoglobin count and mRS at admission (higher hemoglobin was better mRS at admission). This is probably understandable as patients with a better quality of life will have less chance of anemia.

Monocyte count was positively correlated with age (new observation). Monocyte count was associated with the severity of dysphagia. It was associated with NIHSS at admission. Neutrophil count at admission was associated with NIHSS at discharge. Lymphocyte count at admission was associated with mRS at 3 months. Platelet count was associated with mRS at 3 months. Most of these are unique observations and will require further studies to get the right direction.

Paired t-test revealed higher hemoglobin prevalence in males compared to females. Androgens in males might act as stimulant. Paired t-test revealed higher neutrophil count and low lymphocyte counts among hypertensive patients during admission. Mann–Whitney U test revealed a higher total count among diabetic patients (new observation). Interestingly, homocysteine was lower side in ischemic patients with dyslipidemia. Total count was lower among patients with dysarthria, whereas neutrophil count was higher. Packed cell volume (PCV) was higher among ischemic stroke with dysarthria and also those with cardiac problems.

Twenty-four among 100 patients had HHcy. As per the TOAST classification, large artery atherosclerotic disease was the most with HHcy (10 out of 24). It was followed by patients with undetermined stroke etiology who had HHcy (7 out of 24). Subsequently, ischemic stroke with cardioembolic etiology (3 out of 24), followed by small vessel disease (2 out of 24) and stroke with other determined etiology (2 out of 24) had HHy in decreasing frequency.

Fifty-three patients among hundred patients had dyslipidemia (53%). Eighteen among 28 patients of HHy had dyslipidemia (64.28%).

Discussion

A review and meta-analysis showed a dose-response association between Hcy levels and ischemic stroke. In their study, when Hcy levels exceeded 15 μmol/L, a nonlinear association between ischemic stroke and Hcy levels was noted.^[6] However, our idea was to find the relationship in depth. We not only targeted the outcome but also found out the relationship between homocysteine, Vitamin B12 and other demographic parameters, stroke subtypes, and other details. We similarly found out similar relationship between blood counts with all stroke parameters. Our study was the first, as per our knowledge goes, where homocysteine, Vitamin B12 and blood counts together were correlated with ischemic stroke in detail.

Blood counts and stroke

Neutrophil and total leukocyte count correlated with stroke severity. This correlates with earlier studies where the increased neutrophil count and total leukocyte count were associated with severe stroke.^[7],[8] In our study, the lymphocyte count was inversely correlated with stroke severity, including the mRS at 3 months [Figure 1]. This matched with earlier studies. In their study, they detected that lymphocyte levels were significantly lower in very severe stroke cases compared to mild, moderate, and severe cases.^[8] Neutrophil-to-lymphocyte ratio was also significantly higher in severe stroke cases as compared to the mild and moderate stroke groups.^[9]

Figure 1: Low lymphocyte count has higher modified Rankin scale at 3 months

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The increased neutrophil count also correlated with poor swallow and increased incidence of dysarthria, which is understandable as a high neutrophil count was associated with severe stroke where swallow problem and dysarthria are quite obvious. High monocyte count was found to be associated with poor outcomes in stroke.^[10] However, we did not find any such relationship in our study, though we found normal monocyte count in mild-to-moderate stroke [Figure 2]. High neutrophil count and low lymphocyte count were prevalent among hypertensive patients [Figure 3] and [Figure 4]. These findings were like in earlier studies.^[11],[12] High platelet count was associated higher mRS at 3 months. This correlated with earlier studies [Figure 5].^[13]

Figure 2: Normal monocyte count was more associated with moderate stroke

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Figure 3: Increased vitamin B12 is associated with high modified Rankin scale at 3 months

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Figure 4: Hypertensive patients have low lymphocyte count at admission

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Figure 5: Hypertensive patients have increased neutrophil count at admission

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We detected a high blood count among diabetic patients, which is a unique observation. This can be explained because diabetic patients may have larger stroke with increased chance of morbidity and mortality. However, we could not explain why the total count was low in patients with dysarthria.

Although polycythemia vera is already known to have increased cerebrovascular and cardiovascular disease, we could not explain why PCV was associated with increased cardiac disease or dysarthria. These will require further studies.

Serum homocysteine, Vitamin B12, and stroke

Higher serum Vitamin B12 level at admission was associated with higher mRS at 3 months [Figure 6]. This was a unique observation in our study.

Figure 6: Normal monocyte count was more associated with moderate stroke

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In multiple studies, HHy was found to be mostly associated with small vessel disease, and treatment of HHy may affect the outcome in this subtype of stroke.^{[14],[15],[16],[17]} However, a study has also noted HHcy in association with cardioembolic stroke^[18] and predominantly in large artery atherosclerosis in another study.^[19]

We noted HHcy predominantly among patients with large artery atherosclerotic disease.

In their study, HHcy was independently associated with hypertriglyceridemia and low levels of high-density lipoprotein-cholesterol (HDL-C), which provide evidence that Hcy levels might affect HDL-C and triglyceride metabolism.^[20] We found a strong association of dyslipidemia among patients of HHy (64% prevalence).

A study found that the 18-month stroke recurrence rate in the HHcy group (21.0%) was significantly higher than that in non-HHcy group (6.8%). Acute-phase elevated Hcy correlated with severity and prognosis in patients with atherothrombotic stroke.^[21] In their study, they found that elevated homocysteine level was independently associated with a higher risk of all-cause mortality but not recurrent stroke or poor functional outcome in patients with acute ischemic stroke (AIS).^[22] A meta-analysis revealed that the Hcy level might serve as an independent predictor for unfavorable survival outcomes in AIS patients, particularly in Caucasian and Asian AIS patients.^[23] In another study, data showed that elevated Hcy is an independent risk factor for recurrent stroke.^[24] Interestingly, in one study, they found patients with HHcy had a better 3-month outcome.^[25]

In our study, we did not find a significant association between HHcy and recurrent stroke (in 3 months of follow-up) or mortality. The detailed statistical correlations between different parameters in our study are noted in [Figure 7].

Figure 7: Correlations between blood counts, Vitamin B12 level and homocysteine level with demographic and clinical parameters

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Conclusion

We concluded HHcy was associated with large artery atherosclerotic disease (stroke subtype). HHcy did not predict morbidity, mortality, or recurrence on 3 months follow-up. Neutrophil and total leukocyte count correlated with the severity of the stroke, while lymphocyte count was inversely related to stroke severity. Our study shows that simple parameters may show a relationship with ischemic stroke, which may be helpful in management and prognostication. Future studies are required to evaluate these factors and more so that we can understand, prevent, and treat this devastating disease better.

Limitations of our study

We did not have a large sample size; so making any strong comment or recommendation is not possible from our result. Our study, though, had a prospective and retrospective design; a significant number of patients was in the retrospective group, which may cause the biased result. Although we waited for sufficient time, we could not analyze the effect of the acute stress reaction of ischemic stroke patients on plasma Hcy levels. We had insufficient data about Hcy levels before the onset of the stroke and later in illness. Hence, a similar study with a larger sample size is required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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