Abstract
Background and PurposeAcute stroke has a high morbidity and mortality. We evaluated the predictive value of adrenal function testing in acute ischemic stroke. MethodsIn a cohort of 231 acute ischemic stroke patients, we measured dehydroepiandrosterone (DHEA), DHEA-Sulfate (DHEAS), cortisol at baseline and 30 minutes after stimulation with 1 ug ACTH. Delta cortisol, the amount of rise in the 1 ug ACTH-test, was calculated. Primary endpoint was poor functional outcome defined as modified Rankin scale 3–6 after 1 year. Secondary endpoint was nonsurvival after 1 year.ResultsLogistic regression analysis showed that DHEAS (OR 1.21, 95% CI 1.01–1.49), but not DHEA (OR 1.01, 95% CI 0.99–1.04), was predictive for adverse functional outcome. Neither DHEA (OR 0.99, 95% CI 0.96–1.03) nor DHEAS (OR 1.10, 95% CI 0.82–1.44) were associated with mortality. Baseline and stimulated cortisol were predictive for mortality (OR 1.41, 95% CI 1.20–1.71; 1.35, 95% CI 1.15–1.60), but only basal cortisol for functional outcome (OR 1.20, 95% CI 1.04–1.38). Delta cortisol was not predictive for functional outcome (OR 0.86, 95% CI 0.71–1.05) or mortality (OR 0.92, 95% CI 0.72–1.17). The ratios cortisol/DHEA and cortisol/DHEAS discriminated between favorable outcome and nonsurvival (both p<0.0001) and between unfavorable outcome and nonsurvival (p = 0.0071 and 0.0029), but are not independent predictors for functional outcome or mortality in multivariate analysis (adjusted OR for functional outcome for both 1.0 (95% CI 0.99–1.0), adjusted OR for mortality for both 1.0 (95% CI 0.99–1.0 and 1.0–1.01, respectively)).ConclusionDHEAS and the cortisol/DHEAS ratio predicts functional outcome 1 year after stroke whereas cortisol levels predict functional outcome and mortality.Trial RegistrationClinicalTrials.gov NCT00390962 (Retrospective analysis of this cohort).
Highlights
Stroke is the third-leading cause for disability worldwide [1] with an incidence of about 500 per 100’000 persons at the age of 60 and a disease-related mortality of 20% [2].early risk stratification for an optimized allocation of health care resources is warranted.Activation of the hypothalamo-pituitary-adrenal (HPA)-axis has been shown in various acute critical illnesses [3,4]
A dysbalance or inadequate stress response with down-regulation of DHEAS is associated with an unfavorable outcome in severe critical illness, severe sepsis and septic shock in some, but not all studies [14,15,16]
Of the 131 patients with incomplete data that were not included in this analysis, 13 were lost to follow-up, 54% had an modified Rankin scale (mRS) .2 and an unfavourable outcome after 1 year, and mortality after 1 year in these patients was 22%
Summary
Activation of the hypothalamo-pituitary-adrenal (HPA)-axis has been shown in various acute critical illnesses [3,4]. It is one of the first measurable physiological responses to cerebral ischemia [5,6,7,8]. Cortisol levels are predictive of functional outcome in acute stroke [9,10,11]. A dysbalance or inadequate stress response with down-regulation of DHEAS is associated with an unfavorable outcome in severe critical illness, severe sepsis and septic shock in some, but not all studies [14,15,16]. We evaluated the predictive value of adrenal function testing in acute ischemic stroke
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