Background Early prediction of outcome is important for allocation of therapeutic strategies. Endocrine alterations of the hypothalamus–pituitary–axis are one of the first stress-induced alterations after cerebral ischemia. We therefore evaluated the prognostic value of serum cortisol in Chinese patients with an acute ischemic stroke. Methods In a prospective observational study, serum cortisol was measured using a solid-phase, competitive chemiluminescent enzyme immunoassay on admission in serum of 226 consecutive Chinese patients with an acute ischemic stroke. The prognostic value of serum cortisol to predict the functional outcome, mortality within 90 days, was compared with clinical variables (e.g., advanced age and the National Institutes of Health Stroke Scale [NHISS] score) and with other known predictors. Results Patients with a poor outcome and nonsurvivors had significantly increased serum cortisol levels on admission (P<0.0001, P<0.0001). There was a positive correlation between levels of cortisol and the NIHSS (r = 0.298, P<0.0001), glucose levels (r = 0.324, P<0.0001) and infarct volume (r = 0.328, P<0.0001). Cortisol was an independent prognostic marker of functional outcome and death [odds ratio 3.44 (2.58–6.23) and 4.21 (1.89–9.24), respectively, P<0.0001 for both, adjusted for age, the NIHSS and other predictors] in patients with ischemic stroke. In receiver operating characteristic curve analysis, cortisol could improve the NIHSS score in predicting short-term functional outcome (Area under the curve [AUC] of the combined model, 0.87; 95% CI, 0.82–0.92; P = 0.01) and mortality (AUC of the combined model, 0.90; 95% CI, 0.84–0.95; P = 0.01). Conclusion Cortisol can be seen as an independent short-term prognostic marker of functional outcome and death in Chinese patients with acute ischemic stroke even after correcting confounding factors. Combined model can add significant additional predictive information to the clinical score of the NIHSS.
Liu L, Wang D, Wong KS, Wang Y (2011) Stroke and stroke care in China: huge burden, significant workload, and a national priority. Stroke 42: 3651–3654.
Johnston SC, Mendis S, Mathers CD (2009) Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modeling. Lancet Neurol 8: 345–354.
Fassbender K, Schmidt R, Mossner R, Daffertshofer M, Hennerici M (1994) Pattern of activation of the hypothalamic–pituitary– adrenal axis in acute stroke. Relation to acute confusional state, extent of brain damage, and clinical outcome. Stroke 25: 1105–1108.
Fiorentino L, Saxbe D, Alessi CA, Woods DL, Martin JL (2012) Diurnal cortisol and functional outcomes in post-acute rehabilitation patients. J Gerontol A Biol Sci Med Sci 67: 677–682.
O'Neill PA, Davies I, Fullerton KJ, Bennett D (1991) Stress hormone and blood glucose response following acute stroke in the elderly. Stroke 22: 842–847.
Olsson T, Marklund N, Gustafson Y, N？sman B (1992) Abnormalities at different levels of the hypothalamic – pituitary – adrenocortical axis early after stroke. Stroke 23: 1573–1576.
Zetterling M, Engstr？m BE, Hallberg L, Hillered L, Enblad P, et al. (2011) Cortisol and adrenocorticotropic hormone dynamics in the acute phase of subarachnoid haemorrhage. Br J Neurosurg 25: 684–692.
Slowik A, Turaj W, Pankiewicz J, Dziedzic T, Szermer P (2002) Hypercortisolemia in acute stroke is related to the inflammatory response. J Neurol Sc 196: 27–32.
Anne M, Juha K, Timo M, Mikko T, Olli V (2007) Neurohormonal activation in ischemic stroke: effects of acute phase disturbances on long-term mortality. Curr Neurovasc Res 4: 170–175.
Kasner SE, Chalela JA, Luciano JM, Cucchiara BL, Raps EC (1999) Reliability and validity of estimating the NIH stroke scale score from medical records. Stroke 30: 1534–1537.
Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24: 35–41.
Bamford J, Sandercock P, Dennis M, Burn J, Warlow C (1991) Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337: 1521–1526.
Sims JR, Gharai LR, Schaefer PW, Vangel M, Rosenthal ES (2009) ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology 72: 2104–2110.
Mu DL, Wang DX, Li LH, Shan GJ, Li J (2010) High serum cortisol level is associated with increased risk of delirium after coronary artery bypass graft surgery: a prospective cohort study. Crit Care 14: R238.
Parker CR Jr, Slayden SM, Azziz R, Crabbe SL, Hines GA (2000) Effects of aging on adrenal function in the human: responsiveness and sensitivity of adrenal androgens and cortisol to adrenocorticotropin in premenopausal and postmenopausal women. J Clin Endocrinol Metab 85: 48–54.
Astr？m M, Olsson T, Asplund K (1993) Different linkage of major depression to hypercortisolism early versus late after stroke: results from a 3-year longitudinal study. Stroke 24: 52–57.
Anagnostis P, Athyros VG, Tziomalos K, Karagiannis A, Mikhailidis DP (2009) The pathogenetic role of cortisol in the metabolic syndrome: a hypothesis. J Clin Endocrinol Metab 94: 2692–2701.
Krugers HJ, Maslam S, Korf J, Jo？ls M, Holsboer F (2000) The corticosterone synthesis inhibitor metyrapone prevents hypoxia/ischemia-induced loss of synaptic function in the rat hippocampus. Stroke 31: 1162–1172.
Neidert S, Katan M, Schuetz P, Fluri F, Ernst A (2011) Anterior pituitary axis hormones and outcome in acute ischaemic stroke. J Intern Med 269: 420–432.
