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Ghosh et al. Neuroimmunol Neuroinflammation 2018;5:38 I http://dx.doi.org/10.20517/2347-8659.2018.28 Page 9 of 11

tion. Although D-dimer levels are significantly associated with cardioembolic stroke, the significance of D-
dimer levels in relation to the severity and functional outcomes of other stroke subtypes was investigated by
[39]
Kim et al. . Patients with higher D-dimer levels had significantly worse initial functional outcomes, and
these worse outcomes were maintained throughout the 9-month follow-up period compared with the low D-
dimer group. However, regardless of stroke subtype, D-dimer levels did not influence long-term longitudinal
[39]
temporal changes of functional outcomes over the 9-month follow-up period . In our study too, patients
with significantly higher D-dimer levels at admission, had an unfavorable outcome.

[40]
In 2005, Anand and Stead described that serum NSE level was significantly higher in stroke patients than
in controls, and correlated with infarct tissue volume, but did not correlate with the functional outcome.
This was explained by the disparity in sampling time because the NSE level has been shown to peak after
[41]
4-8 h and hence, a better correlation was expected from delayed sampling. However, in 2013, Zaheer et al.
found that NSE level in day 1 positively correlated with infarct volume and functional neurological outcome
at day 30 and negatively correlated with Glasgow Coma Score at presentation. In our study, the mean (SD)
time of presentation of the patients who underwent thrombolysis was 3.8 (0.7) h, and they also had elevated
serum NSE levels. This signifies the requirement of more multicentre research with a larger sample size to
determine the optimum time needed for NSE level to elevate in serum following an acute ischemic stroke.

Limitations
Small sample size confounded the results of factors predicting the severity and outcome of stroke and re-
sulted in wider CI. Even important risk factors like hypertension, hypercholesterolemia, smoking, and AF
could not be established as significant predictors. The short follow up time of 1 month, hindered the evalua-
tion of the long-term neuro-disabilities. The computed tomography machine at our institution does not have
the software to determine the infarct volume and so the correlation of the levels of the biomarkers with the
volume of infarcted tissue could not be done.

What this study adds: (1) EF between 15%-35% also independently predicts severity and the outcome of isch-
emic stroke; (2) MABP and CBG at admission significantly predict severity and outcome of ischemic stroke,
and meticulous management of these factors may improve the outcome; (3) serum NSE level can rise earlier
than 4 h - this fact needs to be validated by other larger studies; (4) fibrinogen level > 478.5 mg/dL at admis-
sion significantly predicts the higher chance of post-thrombolysis haemorrhage; and (5) there is no signifi-
cant difference in the efficacy of intravenous thrombolysis on stroke in various arterial territories.

DECLARATIONS
Authors’ contributions
Provided intellectual inputs: Ghosh KC, Bhattacharya R, Mondal GP
Collected data: Ghosh S, Das S, Mahata M
Prepared the manuscript and acted for correspondence: Das S

Availability of data and materials
The data and material could be available to readers upon request.

Financial support and sponsorship
None.

Conflicts of interest
All authors declare that there are no conflicts of interest.

Ethical approval and consent to participate
The study was approved by Institutional Ethicals Committee, Calcutta National Medical College, Kolkata
and consent was obtained from the patients.