Effect of haemoglobin levels on outcome in intravenous thrombolysis-treated stroke patients

Valerian L Altersberger; Lars Kellert; Abdulaziz S Al Sultan; Nicolas Martinez-Majander; Christian Hametner; Ashraf Eskandari; Mirjam R Heldner; Sophie A van den Berg; Andrea Zini; Visnja Padjen; Georg Kägi; Alessandro Pezzini; Alexandros Polymeris; Gian M DeMarchis; Marjaana Tiainen; Silja Räty; Stefania Nannoni; Simon Jung; Thomas P Zonneveld; Stefania Maffei; Leo Bonati; Philippe Lyrer; Gerli Sibolt; Peter A Ringleb; Marcel Arnold; Patrik Michel; Sami Curtze; Paul J Nederkoorn; Stefan T Engelter; Henrik Gensicke; Thrombolysis in Stroke Patients (TRISP) collaborators

doi:10.1177/2396987319889468

Effect of haemoglobin levels on outcome in intravenous thrombolysis-treated stroke patients

Eur Stroke J. 2020 Jun;5(2):138-147. doi: 10.1177/2396987319889468. Epub 2019 Nov 13.

Authors

Valerian L Altersberger¹, Lars Kellert^{2

3}, Abdulaziz S Al Sultan⁴, Nicolas Martinez-Majander⁵, Christian Hametner³, Ashraf Eskandari⁶, Mirjam R Heldner⁷, Sophie A van den Berg⁸, Andrea Zini⁹, Visnja Padjen¹⁰, Georg Kägi¹¹, Alessandro Pezzini¹², Alexandros Polymeris¹, Gian M DeMarchis¹, Marjaana Tiainen⁵, Silja Räty⁵, Stefania Nannoni⁶, Simon Jung⁷, Thomas P Zonneveld⁸, Stefania Maffei⁹, Leo Bonati¹, Philippe Lyrer¹, Gerli Sibolt⁵, Peter A Ringleb³, Marcel Arnold⁷, Patrik Michel⁶, Sami Curtze⁵, Paul J Nederkoorn⁸, Stefan T Engelter^{1

13}, Henrik Gensicke^{1

13}; Thrombolysis in Stroke Patients (TRISP) collaborators

Affiliations

¹ Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.
² Department of Neurology, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany.
³ Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
⁴ Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
⁵ Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
⁶ Department of Neurology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
⁷ Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
⁸ Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
⁹ Stroke Unit, Department of Neuroscience, Ospedale Civile S. Agostino-Estense, Modena University Hospital, Modena, Italy.
¹⁰ Neurology Clinic, Clinical Centre of Serbia, Beograd, Serbia.
¹¹ Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland.
¹² Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy.
¹³ Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland.

Abstract

Introduction: Alterations in haemoglobin levels are frequent in stroke patients. The prognostic meaning of anaemia and polyglobulia on outcomes in patients treated with intravenous thrombolysis is ambiguous.

Patients and methods: In this prospective multicentre, intravenous thrombolysis register-based study, we compared haemoglobin levels on hospital admission with three-month poor outcome (modified Rankin Scale 3-6), mortality and symptomatic intracranial haemorrhage (European Cooperative Acute Stroke Study II-criteria (ECASS-II-criteria)). Haemoglobin level was used as continuous and categorical variable distinguishing anaemia (female: <12 g/dl; male: <13 g/dl) and polyglobulia (female: >15.5 g/dl; male: >17 g/dl). Anaemia was subdivided into mild and moderate/severe (female/male: <11 g/dl). Normal haemoglobin level (female: 12.0-15.5 g/dl, male: 13.0-17.0 g/dl) served as reference group. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated with logistic regression models.

Results: Among 6866 intravenous thrombolysis-treated stroke patients, 5448 (79.3%) had normal haemoglobin level, 1232 (17.9%) anaemia - of those 903 (13.2%) had mild and 329 (4.8%) moderate/severe anaemia - and 186 (2.7%) polyglobulia. Anaemia was associated with poor outcome (OR_adjusted 1.25 (1.05-1.48)) and mortality (OR_adjusted 1.58 (1.27-1.95)). In anaemia subgroups, both mild and moderate/severe anaemia independently predicted poor outcome (OR_adjusted 1.29 (1.07-1.55) and 1.48 (1.09-2.02)) and mortality (OR_adjusted 1.45 (1.15-1.84) and OR_adjusted 2.00 (1.46-2.75)). Each haemoglobin level decrease by 1 g/dl independently increased the risk of poor outcome (OR_adjusted 1.07 (1.02-1.11)) and mortality (OR_adjusted 1.08 (1.02-1.15)). Anaemia was not associated with occurrence of symptomatic intracranial haemorrhage. Polyglobulia did not change any outcome.

Discussion: The more severe the anaemia, the higher the probability of poor outcome and death. Severe anaemia might be a target for interventions in hyperacute stroke.

Conclusion: Anaemia on admission, but not polyglobulia, is a strong and independent predictor of poor outcome and mortality in intravenous thrombolysis-treated stroke patients.

Keywords: Anaemia; haemoglobin; intravenous thrombolysis; outcome; polyglobulia; stroke.