Original Article DOI: 10.7860/JCDR/2019/37933.12499 Altered Serum Electrolyte Status in Acute Section Biochemistry Stroke Patients in Western Odisha, A Predictor of Syndrome of Inappropriate ADH (SIADH) or Cerebral Salt Wasting Syndrome (CSWS) MANASWINI PANDA1, PRATIMA KUMARI SAHU2, MANMATH KUMAR MANDAL3, ALOK KUMAR MOHAPATRA4, SUBHA SOUMYA DANY5 ABSTRACT urea, creatinine, fasting blood glucose, age, BMI and other Introduction: Stroke is a major healthcare issue globally parameters were studied in these patients. with an incidence comparable to coronary events. It has Results: Out of 60 patients 41 (68%) were males and 19 (32%) multiple aetiologies and variable clinical manifestations. were females. Maximum number of cases had ischaemic stroke Dyselectrolytaemia is an important cause of morbidity and (62%) followed by haemorrhagic stroke (38%). Mean serum mortality in stroke. level of sodium was lower in cases as compared to the controls Aim: To observe the changes in serum electrolyte levels in which was statistically significant (p<0.0001). The serum Cerebrovascular Accident (CVA) patients and to find any relation calcium was lower in cases as compared to the controls which with other biochemical parameters and type of stroke. was statistically significant (p<0.0001). A total of 71.66% of stroke patients had hyponatraemia, while ~48.33% of patients Materials and Methods: A total of 60 clinically diagnosed and had hypocalcaemia. CT/MRI proven acute stroke patients (ischaemic/haemorrhagic) in age group 40-70 years were studied in the Department of Conclusion: Dyselectrolytaemia is highly prevalent in stroke Biochemistry, VIMSAR, Burla, for a duration of two years patients. Dyselectrolytaemia also varies with the type of stroke. (September 2013 to August 2015). Control group consisted Thus, serum electrolytes should be a part of the initial evaluation of 50 age and sex matched individuals. Serum electrolytes, in all stroke patients to prevent morbidity and mortality. Keywords: Dyselectrolytaemia, Haemorrhagic stroke, Ischaemic stroke INTRODUCTION stroke is headache and vomiting [7]. Vomiting is an important The World Health Organisation (WHO) defines stroke (previously cause of dyselectrolytaemia. In acute phase, complications like known as cerebrovascular accident or CVA) as rapidly developing dyselectrolytaemia are more common [6]. This electrolyte imbalance clinical symptoms and/or signs of focal and at times global may lead to shift of extracellular fluid to intracellular fluid, ultimately (applied to patients in deep coma and those with subarachnoid causing brain oedema. These changes in electrolytes and water haemorrhage) loss of brain function, with symptoms lasting more concentration can result in severe complications. than 24 hours or leading to death, with no apparent cause other Serum electrolytes can be easily measured in emergency service than that of vascular origin. About 85% of all first ever stroke are settings. Studies describing electrolyte status in CVA are rare in ischaemic, 10% are due to primary intracerebral haemorrhage and western Odisha. If they are estimated and corrected in early phase; 5% are due to subarachnoid haemorrhage. patients will have a better prognosis. This study was therefore Stroke is a major healthcare issue worldwide with an incidence undertaken to observe the changes in serum electrolyte levels in CVA patients and to find any relation with other biochemical comparable to coronary events, highlighting the importance of parameters and type of stroke. understanding risk factors for stroke and subsequent mortality. Stroke is the third most common cause of death in developed MATERIALS AND METHODS nations after ischaemic heart disease and cancer [1]. The prevalence The present study was undertaken in the Department of Biochemistry, rate of stroke in India is about 1.54 per 1000 and death rate 0.6 per VSS Institute of Medical Sciences and Research (VIMSAR), Burla, 1000 [2]. Advanced age, hypertension, diabetes mellitus, smoking Odisha, India, on diagnosed cases of acute stroke, admitted to the and atrial fibrillation have been found to be risk factors for stroke Department of General Medicine, during the period of September and relevant mortality in prospective studies [3]. 2013 to August 2015 (two years). It was a retrospective case control Medical management of stroke focuses on the prevention of study and included a total of 60 clinically diagnosed and Computed sub-acute complications of stroke like malnutrition, aspiration Tomography/Magnetic Resonance Imaging (CT/MRI) proven acute pneumonia, electrolyte disturbances, bowel or bladder dysfunction, stroke patients (ischaemic/haemorrhagic) in the age group of 40- Deep Vein Thrombosis (DVT), pulmonary embolism, contractures, 70 years. Control group consisted of 50 age and sex matched joint abnormalities and skin breakdown [4]. normal healthy individuals. Complications such as seizure or death in stroke may be due to Pregnant females, patients receiving dialysis for Chronic Renal electrolyte disturbances resulting from Syndrome of Inappropriate Failure (CRF), patients with severe hyperglycaemia (>300 mg/dL), Antidiuretic Hormone (SIADH) or Cerebral Salt Wasting (CSW), hyperlipidaemia, persons receiving medications altering serum elevation of Brain Natriuretic Peptide (BNP), inappropriate fluid intake electrolytes including anti-hypertensives, cases of subarachnoid or loss [5,6]. Most common clinical presentation in haemorrhagic haemorrhage, convulsive disorder, and patients with liver disease 10 Journal of Clinical and Diagnostic Research. 2019 Jan, Vol-13(1): BC10-BC13 www.jcdr.net Manaswini Panda et al., Altered Serum Electrolyte Status in Acute Stroke Patients were excluded from the study. Patients who did not survive the Controls (n=50) Cases (n=60) stroke incident were not included into the study. All procedures Parameters p-value Mean±SD Range Mean±SD Range performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or Age (Years) 58.88±8.12 40-70 59.78±7.64 41-70 >0.05 national research committee. BMI (kg/m2) 21.98±2.25 19.6-24.8 25.51±3.08 24.8-30.2 <0.0001 Blood pressure was measured by standard sphygmomanometer SBP (mm Hg) 124.76±10.37 110-136 174.13±17.68 146-176 <0.0001 with right arm in supine position. A structured questionnaire was DBP (mm Hg) 80.21±3.13 75-89 99.33±7.99 91-116 <0.0001 used to obtain data on family history of diabetes and/or hypertension, [Table/Fig-3]: Clinical parameters in the groups studied. past and present illness, dietary pattern, addiction, and medication. Approval from the ethical committee was obtained before the study Parameters (mg/ Controls (n=50) Cases (n=60) p-value and informed consent was obtained from participants or their dL) Mean±SD Range Mean±SD Range relatives. Patients admitted within 48 hours of the onset of stroke FBS 86.36±8.21 70-104 88.08±9.36 70-120 p>0.05 were enrolled for this study and at the same time samples were Urea (mg/dL) 33.94±5.51 22-44 39.72±18.34 21-78 <0.05 collected for assessment. Samples were analysed immediately without any delay. Association of electrolyte imbalance among Creatinine (mg/dL) 0.98±0.23 0.5-1.4 1.54±0.71 0.5-3.1 <0.0001 stroke patients were identified and correlated. [Table/Fig-4]: Comparison of biochemical parameters in study groups. Anthropometric parameters like height (cm), weight (kg), and Body [Table/Fig-5-7] shows that serum sodium in controls was Mass Index (BMI) was calculated during the time of admission and 138.86±7.28 mEq/L with a range of 125-146 mEq/L and for blood pressure was taken in normal supine posture three times cases 128.48±4.61 mEq/L with a range of 122-146 mEq/L. and the mean was used. Biochemical parameters like fasting Serum sodium was lower in cases as compared to the controls blood glusose (FBG) and lipid profile (Total cholesterol, Triglyceride, which was statistically significant (p<0.0001). Serum potassium in HDL) were estimated in all subjects as per standard guidelines controls was 4.432±0.51 mEq/L and for cases 4.49±0.55 mEq/L. [8-11]. The estimation was done by the help of semi-automated The difference was statistically not significant (p>0.05). Serum Biochemical Analyser (ACCULAB-AT-112+) using marketed kits. chloride level in controls was 101.48±4.25 mEq/L and for (ACCUREX Diagnostics). Serum electrolytes were estimated by cases 101.17±3.81 mEq/L. The difference was statistically direct Ion Selective Electrode (ISE) method enlite series electrolyte not significant (p>0.05). Serum calcium level in controls was analyser (Accurex biomedical pvt., ltd.,) [12]. Hyponatraemia and 9.00±0.53 mg/dL and for cases 8.6±0.46 mg/dL. [Table/Fig-8] hypocalcaemia were considered if serum levels of sodium and shows that serum sodium was positively correlated to serum calcium were <135 mEq/L and 8.7 mg/dL respectively. All data were urea in suspected SIADH cases and negatively correlated to collected in case record form. Association between variables were serum urea in suspected CSWS cases, which was statistically determined using Microsoft Excel. Correlation between parameters significant. was analysed using the Statistical Package for the Social Sciences (SPSS) version 20 software. Controls (n=50) Cases (n=60) Parameters p-value RESULTS Mean±SD Range Mean±SD Range The study comprised of 60 diagnosed cases of clinically and S.Sodium (mEq/L) 138.86±7.28 125-146 128.48±4.61 122-146 <0.0001 CT/MRI proven acute stroke patients (ischaemic/haemorrhagic) S.Potassium (mEq/L) 4.432±0.51 3.4-5.3 4.49±0.55 3.2-5.4 >0.05 and 50 age and sex matched normal healthy persons as control S.Chloride (mEq/L) 101.48±4.25 96-110 101.17±3.81 94-110 >0.05 [Table/Fig-1,2].