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Ghosh et al. Neuroimmunol Neuroinflammation 2018;5:38 I http://dx.doi.org/10.20517/2347-8659.2018.28 Page 3 of 11

acute thrombosis have also been associated with ischemic stroke, including fibrinogen, D-Dimer and von-
[10]
Willebrand factor .

Few studies have systematically evaluated the multimodal factors (demographic, clinical, radiological and
biological markers) in unselected consecutive first-ever ischemic stroke patients. This article aims to identify
the factors that can independently prognosticate the acute phase of ischemic stroke.

METHODS
All patients with the first episode of ischemic stroke admitted to the Neurology Department between 1st
December 2017 to 30th April 2018 were included in this pilot study and written informed consent was taken
from the patients or their family members to participate in the study. Stroke was defined according to the
[11]
World Health Organisation criteria . Ischemic stroke was diagnosed with a combination of clinical criteria
and non contrast computed tomography imaging of brain, which was done for all patients upon admission,
to exclude intracerebral hemorrhage. We recorded the medical history prior to the stroke and the conges-
tive heart failure, hypertension, age, diabetes mellitus, prior stroke or transient ischemic attack (TIA), or
thromboembolism (CHADS2) scores were calculated for all patients. The following variables were analyzed:
gender, age, domestic arrangements (lives with other family members or alone), clinical history, and medi-
cations, vascular risk factors including history of hypertension, diabetes mellitus, heart diseases [ischemic
heart disease, low ejection fraction and atrial fibrillation (AF), as a history of AF and/or AF diagnosed dur-
ing the index admission by electrocardiography], TIA, current or former smoking, and hypercholesterol-
emia. Stroke severity was evaluated in the acute phase of the initial stroke by a neurologist certified in the
[12]
use of the National Institute of Health Stroke Scale (NIHSS). Stroke severity by NIHSS was categorized as
mild (0-4), moderate (5-15), or severe (16-42). Furthermore, strokes were classified according to the Bamford
[13]
criteria in total anterior circulation stroke (TACS), partial anterior circulation stroke (PACS), posterior
circulation stroke (PCS), and lacunar stroke (LS). Patients being admitted within 4.5 h of onset of symptoms
were thrombolysed with injection alteplase, provided they did not have the contraindications for thromboly-
sis. For each patient, 4 serum biomarkers [(D-dimer, fibrinogen, CRP and Neuron specific enolase (NSE)]
were evaluated at admission and 24 h later. D-dimer was assessed using enzyme linked immunosorbant as-
say (ELISA) kits from GenWay Biotech, San Diego, California, USA, and a level of more than 4 µg/mL was
considered high. NSE was assessed using human NSE ELISA kit (Elabscience Biotechnology Co. Ltd., Hous-
ton, USA) and the normal value at spectrophotometers in the 450 nm wavelength was 7.2-12 ng/mL. Serum
concentrations of CRP were quantified using a commercially available turbidimetric immunoassay (Transasia
Bio-Medicals Ltd., Erba Diagnostics, Mannheim, Germany) and value < 6 mg/L was considered normal.
Fibrinogen was assayed by FibroTek fibrinogen kit (R2 Hemostasis Diagnostics India Private Limited, Indira
Puram, Ghaziabad, Uttar Pradesh) and the value of 150-400 mg/dL was considered normal.

Follow-up magnetic resonance imaging examination (1.5 Tesla system providing axial T1, T2, and proton
density weighted images) or brain CT scan was repeated 5 days after the index event. Metabolic profile (re-
nal and liver function tests); and hematologic parameters (complete hemograms and coagulation profile)
were recorded in the registry on arrival and again at 24-48 h after stroke onset. The cardiological profile
(electrocardiogram and transthoracic echocardiography) and a search for vasculitis (antinuclear factor and
antiphospholipid antibodies) were also done. Previous infections were excluded by medical history, chest
radiograph, routine urinalysis, and complete physical examination. The vital parameters were recorded con-
tinuously using multi-parameter monitors. The length of hospital stay was defined from the day of admis-
sion to a hospital ward to the day of discharge. Acute stroke management and secondary prevention in these
[14]
patient followed current European Stroke Organization guidelines . Discharged patients were followed up
on a monthly basis through neurological examination and review of records. Their clinical outcomes were
assessed using the modified Rankin scale (mRS) and categorized as favorable (score 0-1) or unfavorable (score
2-6). Exclusion criteria included history of recent infection, obvious signs of acquired infection before stroke