INTRODUCTION In urban India stroke accounts for 1% mortality of all hospital admissions, 4% in all medical cases and about 20% in all disorders of central nervous sys- tem. Risk factor for stroke inc ludes diabetes , hyper- tension, smoking and hyperlipidemia and these have been linked to abnormalities of haematology and co- agulation such as increased brinogen. Stroke is dened as an abrupt neurologic decit that is at- tributable to focal vascular cause. Risk factors for stroke are hypertension, atr ial bri l lat ion, carot id stenosis, hyperlipidemia, diabetes, myocardial infarc- tion, atrial myxomas and smoking. Fibrinogen is a soluble plasma glycoprotein that con- sists of three nonidentical pairs of polypeptide chains chains). In the rst phase of throm- bus formation soluble brinogen is converted into brin peptides initiate a process in which brin monomers begin to gel. These brin monomers polymerise to form brin polymers. This process continues and elongation of polymers causes formation of protobrils. Once a critical Mass of long proto brils is established, the protobrils form lateral contacts with other protobrils thereby forming brin clot. Fibrin clot thereby potentiates formation of thrombosis. Epidemiological observations indicate that high plasma brinogen levels strongly correlate with the frequency of two major thrombotic complications of atherosclerosis, stroke as well as myocardial infarction. Thrombosis is increasingly recognized as a central mechanism in stroke and myocardial infarction, and brinogen is believed to be involved in events thought to play a major role in thrombosis. Therefore elucidation of the relationship between brinogen and thrombosis may strengthen the predictive value of this protein and suggest new treatment in management of stroke. Hence this study is designed to investigate the association between plasma brinogen levels and acute stroke. METHODOLOGY The present study was a cross sectional study done in the Medicine ward/ICU. Plasma brinogen level was done of 50 patients presenting with acute stroke admitted in Medicine ward/I.C.U of sree balaji medical college &hospital from January 2019 to July 2019. Method of collection of data: The study was carried out on 50 consecutive patients admitted to Medicine ward/I.C.U of sree balaji medical college& hospital, Chennai with acute stroke within 24 hour of symptoms. Detailed history were taken to nd out the risk factors such as hypertension, diabetes, Smoking and overweight. Hypertension was diagnosed by JNC VIII criteria. Diabetes was diagnosed by American Diabetes Association criteria. Smoking was recorded in terms of number of cigarette pack years smoked. Thorough general and systemic examination was carried out. In addi- tion to routine investigations as per standard proto- col in the evaluation of stroke patient, fasting plasma brinogen level was estimated. Patients were followed up till they were discharged from the hospital. Inclusion Criteria: All patients fullling all of the be- low criteria were included in the study 1) Patients presenting with acute stroke within 24 hours of onset of symptoms & CT/MRI scan. Shows cerebral infarct or haemorrhage. 2) Patients willing to give informed written con- sent. Patients with evidence of uremia, infection, active hepatic disease, active hepatic disease, undergone surgery in last three months and not willing to give informed written consent were excluded from the study. Detailed history, clinical examination and relevant laboratory investigations were done as per profor- ma.Fasting plasma A STUDY ON FIBRINOGEN LEVELS IN PATIENTS OF ACUTE STROKE Original Research Paper Dr. G. Venkat Sai* Junior Resident, Department Of General Medicine , Sree Balaji Medical College , Chennai, Tamil Nadu. * Corresponding Author X 107GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS General Medicine Introduction: Risk factor for stroke includes diabetes, hypertension, smoking and hyperlipidemia and these have been linked to abnormalities of haematology and coagulation such as increased brinogen. The present study is designed to investigate the association between plasma brinogen levels and acute stroke. Methodology: The present study was a cross sectional study done in the Medicine ward/ICU of a tertiary care hospital. Plasma brinogen level was done of 50 patients presenting with acute stroke admitted in Medi- cine ward/I.C.U of sree balaji medical college& hospital. Detailed history was taken to nd out the risk factors such as hyper- tension, diabetes, Smoking and overweight. In addition to routine investigations as per standard protocol in the evaluation of stroke patient, fasting plasma brinogen level was estimated. Results: The mean age in the present study was 58.52 years. The maximum numbers of patients were in the age group 60-69 years. In 86% of cases were having higher brinogen level. There were 23(46%) smokers among patients. Non smokers, Normotensives, Non obese and non diabetics had higher brinogen levels than smokers which were not statistically signicant. Conclusion: Mean brinogen level was lower in patients of acute stroke with any of risk factors like smoking, hypertension, diabetes and obese than in patients of acute stroke without any of these risk factors. This differ- ence was not statistically signicant in this study but further large study can be planned to prove this. ABSTRACT KEYWORDS : Acute Stroke, Fibrinogen, Hypertension, Diabetes VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Dr. N. N. Anand Professor, Department Of General Medicine , Sree Balaji Medical College , Chennai, Tamil Nadu. l ( Aa Bb and 108 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS brinogen was estimated in patients and age, sex and risk matched controls.The plasma brinogen was measured quantitatively by Clauss method. Venous blood was collected in an evacuated sili- conized blood collection tube containing 1 volume 0.11mol/lt of Sodium citrate (3.8%) and 9 volumes of whole blood, which was centrifuged for 15 min at RCF of 2000g.The buffer which was provided in the Dade Behring brinogen estimation kit was used to Prepare 1:10 dilution of patient's plasma sample 0.2ml diluted (50µl) citrated plasma sample was incubated for 1 minute, then 25µl of thrombin reagent was added at room temperature 0 and clotting time was then determined at 37 centigrade using a coagulation instrument. RESULTS There total 50 patients presented with acute stroke within 24 hours of onset of symptoms & CT/MRI scan and fullling inclusion criteria. This all patients were included in the study. Table 1: Age wise and brinogen level wise dis- tribution of cases (N=50) Table 2: Gender wise distribution of cases and their mean brinogen level (N=50) Table 3: Relation of different risk factors with mean brinogen level The mean age in the present study was 58.52 years. The youngest patient was of age 35 years. The oldest patient was of age 84 years. The maximum numbers of patients were in the age group 60-69 years. In the present study minimum plasma brinogen level was 180mg/dl and maximum was 850mg/dl. Normal brinogen value is 150-400. In 86% of cases were having higher brinogen level. Among 50 patients studied, 62% were Male and 38% were Female. Males had mean brinogen of 595 and females had mean brinogen of 641. This difference was not statistically signicant. (p-Value > 0.05) In the present study there were total 44 patients were having ischemic strokes and their mean brin- ogen level was 615 mg% and there were total 6 pa- tients were having haemorrhagic strokes and their mean brinogen level was 588 mg%. There were 23(46%) smokers among patients. Non smokers had higher brinogen levels than smokers which were not statistically signicant.Among nor- motensive patients mean brinogen level was higher than hypertensive patients, mean values in hyperten- sive was 563 whereas it is 648 in patients who are normotensive. This difference was not statistically signicant. In present study non diabetics had higher brinogen levels which were not statistically signi- cant. In patients who were obese, mean brinogen level was 597 and in non obese patients, mean - brinogen level was 632. Non obese patients had higher brinogen level than obese individuals. The difference was not statistically signicant. DISCUSSION The present study involved 50 patients presenting with acute stroke admitted in Medicine ward/I.C.U. The mean brinogen level was 615 mg% in ischemic group. Mistry PP et al., in their study involving 56 pa- tients admitted in the hospital within 24 hours of on- set of symptoms. The levels were found to be raised signicantly (531.73mg %) compared to those of the age and sex matched control group (445.78mg %). When the levels of plasma brinogen in stroke group with one risk factor were compared to those of indi- viduals with comparable control group with same risk factor, a signicant difference was observed. Hazra B et al., in their study involving 33 patients of cerebral thrombosis and 30 patients with cerebral hemorrhage admitted within 24 hours of onset of stroke conclud- ed that the mean plasma brinogen concentration in patients of cerebral thrombosis (378.67 mg/dl) is sig- nicantly higher when in the control group (216.67). Variation in the level of brinogen in the above studies may be due to variation in ethnicity or the method of brinogen assay or may be due to age group and sex of the patient selected for the study. AJ lee and TW Maede have shown that brinogen level increases with age. This study also demonstrates an increasing trend of brinogen with age. Fibrino- lytic activity reduces as age advances because of, As age advances there is change in orientation of gpIIa/IIIb receptor causing decreased brinolytic activity which accounts for increased plasma brino- gen levels as age advances. It is likely that mutation accumulation of plasma - brinogen plays a signicant role in the changes of - brinogen with age. The increase of variance with age is the product of unrepaired evolutional damage in different levels of organization, and the mutations causes increased - brinogen levels as age advances. AJ lee and TW Maede11 have shown males have higher brinogen when compared to females. This study has shown that brinogen was increased in females than males amongst Higher brinolytic ac- tivity in females explained the lower brinogen levels in females when compared to males. Ernst E has demonstrated that smoking is associated with in- creased plasma brinogen levels. VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Variables No. (%) Age group (in years) 30-39 3 (6.0) 40-49 11 (22.0) 50-59 11 (22.0) 60-69 15 (30.0) >70 10 (20.0) Fibrinogen level (mg/dl) Less than 200 2 (4.0) 200-400 5 (10.0) 400-800 43 (86.0) Gender No. (%) Mean +- SD p-Value Males 31 (62.0) 595.16± 195.26 0.40477 Females 19 (38.0) 641.05±173.46 Patients No.Mean(mg%) brinogen p-Value Smoking Smokers 23 596.09±204.02 0.539199 Non smokers 27 629.26±175.32 Hypertension Hypertensive 21 563.81± 206.09 0.113364 Normotensive 29 648.62±165.55 Diabetes Diabetic 15 545.33±210.84 0.0907205 Non diabetic 35 643.43± 171.94 BMI >30 9 597.78±169.02 0.613588 <30 41 632.16±186.56 This study has shown increased brinogen levels in patients amongst smokers as compared to non- smokers which was not statistically signicant. Other studies have demonstrated that in smokers, the plasma brinogen is elevated because, Smoking activates lung macrophages which releases IL-4 which increases brinogen synthesis14Smoking decreases brinolytic activity. Smoking causes endothelial damage resulting in acti- vation of coagulation system and release clotting fac- tors. Anjula Jain et al has demonstrated brinogen levels are higher in hypertensives. Lee AJ has demonstrat- ed plasma brinogen was higher among hyperten- sive. In this study hypertensive patients had higher brinogen than normotensives which was not statis- tically signicant. Several pausible mechanisms could explain an ob- served association between elevated brinogen levels and hypertension, Relation of brinogen to increased viscosity and pe- ripheral vascular resistance. Hyperinsulinemia and insulin resistance is common amongst hypertensive and hyperinsulinemiais known to cause decreased brinolytic activity. Hence in- creased brinogen levels in hypertensives. Markers of inammation, such as IL-6 and IL-8 are elevated in hypertension and causes reduced con- sumption of brinogen, thereby contributing to in- creased plasma brinogen in hypertension, increased platelet activation, increased activity of the coagula- tion system and decreased function of the brinolytic system. Meade TW and Ernst E have shown that obese individuals have higher brinogen levels. Obese in-dividuals had higher brinogen levels compared to non-obese patients which were not statistically sig- nicant. The mechanisms underlying increased plasma - brinogen in patients who had over weight are, There is a positive association between obesity (skin fold t h i c k n e s s ) a n d p l a s m a i n s u l i n c o n c e n t r a t i o n , hyperinsulinemia thereby stimulates brinogen syn- thesis. It is possible that the interaction between obesity and physical inactivity may promote dyslipidaemia and increased plasma brinogen. In this study diabetics had higher brinogen than non diabetics.The exact mechanism of increased - brinogen levels in diabetics is unknown, possible mechanisms include, Insulin stimulates cholesterol synthesis in smooth muscle cells and macrophages of the arterial walls, stimulates the proliferation and migration of smooth muscle cells. It also enhances the formation of - brinogen. Endothelial dysfunction which is common in diabet- ics, which causes decreased brinolytic activity and hence increased plasma brinogen levels. The plasma glucagon concentration is positively re- lated to the plasma brinogen concentration. Thus,brinogen production is markedly enhanced in diabetic patients, and this alterationis likely to deter- mine the observed hyperbrinogenemia in these pa- tients. Hyperglucagonemia may contribute to the in- creased brinogen production. Thus, insulin concentrations (and probably also glu- cose proles) may need to be maintained at the low- est attainable level in type 2 diabetes to prevent in- creased brinogen synthesis and concentrations. CONCLUSION The maximum numbers of patients of acute stroke were in the age group 60-69 years. Mean brinogen level was lower in patients of acute stroke with any of risk factors like smoking, hypertension, diabetes and obese than in patients of acute stroke without any of these risk factors. This difference was not sta- tistically signicant in this study but further large study can be planned to prove this. REFERENCES 1. Lee AJ, Lowe GD, Woodward M, Pedoe TH. Fibrinogen in relation to personal history of prevalent hypertension, diabe- tes, stroke, intermittent claudication, coronary heart disease and family history. The Scottish Heart Health study. Br Heart J 1993; 69:338-342. 2. Fu A and Nair S K. 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