We found that ECG abnormalities in patients with acute stroke are very common, especially tachycardia. The site of lesion appears to play major factor as a cause of genesis of arrhythmia. Concomitant cardiac diseases may present .Serum troponin elevation may play a role in diagnosing neuro-cardiogenic injury but, ECG appears to be more sensitive and familial.
Mean age in this study was 70.3+/-6.4sd. 60% were in age ranging from 50 to 75. Of all 50 patients included in this study 26 were males (52%), (48 %) were females. The majority of them reside in Khartoum State. Risk factors like hypertension affects the majority of this group(68%). While 22% were diabetic and 26% were smokers or tobacco users. Hyperlipidemia was found in 10% of these patients identified by lab results or clinically by presence of exanthemata or exanthema. Also 10% of patients had a history of TIA. 6% of them had a history of alcohol consumption. Regarding cardiac disease 6% with history of chronic AF, 4% known to have ischemic heart disease, 4% diagnosed with valvular lesions. 12% show no obvious risk factors. Unlike the Turkish study, there was no advanced cardiac evaluation as echocardiogram is not performed at the level of casualty. The suspected stroke patients were 48 using the Rosier scale. As diagnosis of stroke is unlikely if the score below zero, strokes in 2 patients scoring zero were confirmed by imaging. Stroke confirmed by CT scan in 41 patients (82%), while 9 patients (18%) underwent MRI imaging. In this study 50 % of strokes were ischemic in nature, 46% were hemorrhagic in 25, 23 patients respectively. 2 patients identified with subarachnoid hemorrhage. Localizing stroke identifies the following: Both ischemic and hemorrhagic stroke tends to favor the temporoparietal regions (20% of hemorrhagic stroke/18% of ischemic).
Basal ganglia was the second affected area (8% of patients developed ischemia at this area, 8% have hemorrhage at this site). Both temporoparietal and basal ganglia are supplied by the middle cerebral artery (anterior circulation). This is followed by the occipital parietal area as 6% suffered hemorrhagic stroke at this area while 8% developed ischemic stroke. 37 patients of this study (74%) suffers from a stroke involving the anterior circulation (anterior and middle cerebral arteries). Sadber mentioned autonomic control were decreased in patients with stroke and more pronounced decrease is found in territory middle cerebral artery insular cortex(14). All traces in this study showed ECG abnormalities, the most frequent changes was tachycardia present in 27 patients( 54%). LVH features found in 24/34 of hypertensive patients. Bradycardia and ST depression, share the same percentages of 20%. T wave inversion observed in 10%.in contrast to Goalmerza et.al who mentioned ST depression, T inversion as the most frequent changes, same goes for another study done by Kokoschka Ibrahim et al.
Our observation was similar to what was achieved by Sullvin Lavy who found that both disturbances in rhythm, conduction and ischemic-T alteration were detected but frequency of the former exceeded that of later. Supra ventricular arrhythmias were caught; AF was the most frequent 12%, although half of them are known cases of chronic At. This is followed by atrial flutter, SVT, PCA, also those findings are similar to findings of the Iranian study. In this study a fatal arrhythmia VF was seen once. Other ECG changes were observed in small proportions are RBBB, LBBB, abnormal Q waves, prolonged QT interval. Regarding rate changes and location; tachycardia was more frequently identified in the temporoparietal lesions. 14% affect the right temporoparietal lobe .12% affect the left. Bradycardia was a closed finding to occipital, occipetoparietal lesions, and was documented in subarachnoid hemorrhage. The relation of rhythm changes to stroke location has no statistical significance (p= 0.9) more than 0.05. A rare finding was presence of bradycardia in left temporoparietal stroke; this may explain the dominant parasympathetic tone of left insula. But lateralization showed no statistical significance in this study.
Troponin I is a sensitive marker of cardiac alteration, elevated in myocardial infarction, myocarditis, pericarditis, atrial fibrillation and heart failure. Elevated troponin I also has been found in patients with chronic renal failure, sepsis, critical illness, pulmonary embolism and COPD.
Elevated levels of troponin have been reported in 10-34% of patients with acute stroke (Kerr et al)(15). In this study 14 % have positive readings matching what have been reported. Trying to localize stroke in those with positive troponin (7 patients), it was clear that all of them have an anterior circulation stroke. (5/7) suffered temporoparietal stroke. The other two patients presented with basal ganglia stroke. All of them showed ECG changes. Increased heart rate, supraventricular arrhythmias were recognized. And fatal ventricular fibrillation was identified in one patient. The Turkish study state that 5 patients with RMCA- insular lesions died suddenly compared with two patients of LMCA –insular lesions during hospitalization which suggests that cardiac autonomic tone may be regulated by insula, and that these patients are more prone to cardiac complications such as arrhythmias. In this study it is found that ST segment /T wave inversion is more seen with the right temporoparietal lesions more than the left lesions.
Strength and Limitations:
To our knowledge this is the first study to be done in Sudan concerning this topic. We emphasized on being strict with the inclusion and exclusion criteria of selecting proper candidate to enter the study to ensure highest possible accuracy.
As any study, we had some limitations. First of all, the sample size wasn’t big because in such situations, as for patients with stroke, the condition of the patients is usually critical, so it wasn’t easy to collect more samples. Also the number of the doctors wasn’t enough to collect samples, as many of the doctors were busy with the events of the Sudanese evolution at that time. Also we couldn’t do many investigations nor investigated all the patients due to the lack of proper facilities.
Recommendation:
ECG changes which are justifying intensive monitoring. Locating the stroke may reflect future cardiac dysfunction. Identifying preexisting cardiac disease is important. Advanced facilities such as echocardiography are needed at the level of causality/Emergency room. Improving stroke care capabilities may improve stroke outcomes.