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Year : 2021  |  Volume : 24  |  Issue : 1  |  Page : 10-14

A case–control study to evaluate the role of mean platelet volume and platelet distribution width in acute ischemic stroke

1 Department of General Medicine, Mahatma Gandhi Medical College and Research Institute, SBVU, Pondicherry, India
2 Department of Pathology, Mahatma Gandhi Medical College and Research Institute, SBVU, Pondicherry, India

Date of Submission03-Sep-2020
Date of Decision08-May-2020
Date of Acceptance27-May-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Mohamed Hanifah
Department of General Medicine, Mahatma Gandhi Medical College and Research Institute, Pondicherry - 607 403
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DOI: 10.4103/smj.smj_19_20

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Background: Ischemic stroke is known to be one of the foremost causes of long-term disability and death, and platelets play a pivotal role in its pathophysiology. However, the platelet indices having a role in ischemic stroke are not routinely reported in the available literature. Objective: The objective of the study was to evaluate the potential role of mean platelet volume (MPV) and platelet distribution width (PDW) in the development of ischemic stroke, especially in the South Indian region. Materials and Methods: This case–control study was conducted on 80 patients who were broadly divided into two groups: the case group (patients with ischemic stroke) and the control group (patients without ischemic stroke). Platelet indices were measured using Mindray BC-5200 auto hematology analyzer, and the results were analyzed using Student's t-test and Wilcoxon rank-sum Test. Results: There was a statistically significant difference (P < 0.001) in the MPV and PDW values between the two groups. The difference between the area under the curve for both MPV and PDW was also found to be statistically significant (P < 0.001) in the receiver operating characteristic curve. However, the differences in the values of MPV and PDW across different age groups, genders, and various comorbid conditions were not found to be significant. Conclusion: The elevated platelet indices may be associated with the development of ischemic stroke. The MPV and PDW can be prospective biochemical markers for predicting the onset of ischemic stroke.

Keywords: Blood platelets, brain ischemia, hematology, mean platelet volume, receiver operating characteristic curve

How to cite this article:
Sundari M, Hanifah M, Kotasthane DS, Jayasingh K. A case–control study to evaluate the role of mean platelet volume and platelet distribution width in acute ischemic stroke. Sahel Med J 2021;24:10-4

How to cite this URL:
Sundari M, Hanifah M, Kotasthane DS, Jayasingh K. A case–control study to evaluate the role of mean platelet volume and platelet distribution width in acute ischemic stroke. Sahel Med J [serial online] 2021 [cited 2021 Jun 18];24:10-4. Available from: https://www.smjonline.org/text.asp?2021/24/1/10/312736

  Introduction Top

Stroke is a clinical syndrome, of vascular origin rather than a single disease. The World Health Organization (WHO) defines stroke as a focal or global cerebral dysfunction manifesting rapidly in clinical symptoms that last for more than 24 h. [1],[2] It is one of the chief causes of continuing disability and mortality worldwide, especially in developing countries. According to the WHO, about 33% of the stroke patients (approximately 15 million) die, and a similar number of them (about 33%) develop a permanent disability. Worldwide, an incident of stroke occurs every half second, and a life is lost every 10 s due to stroke.[3] In India, it is estimated that about 84–262 people of 100,000 in rural areas and 334–424 of 100,000 in urban areas suffer from a stroke.[4] Ischemic strokes are of various types including cortical strokes, lacunar strokes, and posterior circulation strokes.[5]

Platelets develop intravascular thrombus after erosion or rupture of atherosclerotic plaques, leading to a stroke.[6] The thrombotic potential of platelets depends on their size. Larger platelets have a high thrombotic potential as they contain more granules, higher thromboxane A2 level, tend to express more glycoprotein Ib and IIb/IIIa receptors, and aggregate more rapidly with collagen.[7] The mean platelet volume (MPV) and platelet distribution width (PDW) are theoretically useful biomarkers in the early detection of thromboembolic diseases.[5]

MPV is an autonomous risk factor for the development of ischemic stroke that is secondary to the platelet thrombopoietic reactivity.[8],[9],[10] Similarly, PDW is another determinant of platelet function that is used as a marker for the early prediction of ischemic stroke.[11] There are many international studies on the role of platelet indices in stroke patients. However, there is a paucity of available data in the Indian population. Therefore, this study was conducted to determine the significance of platelet indices, including MPV and PDW, in acute ischemic stroke patients in the South Indian region.

The objectives of this study also include the comparison of MPV and PDW in the case group (patients with acute ischemic stroke) and control group (patients without acute ischemic stroke) and assessment of the receiver operating characteristic (ROC) curve to find the cutoff points of MPV and PDW for detecting acute ischemic stroke.

  Materials and Methods Top

Study design

This case–control study was conducted on a total of 80 patients who were admitted to the intensive care unit from January 2016 to May 2017. The institution's ethical committee approval (P. G DISSERTATION/2015/10/39) by the Institutional Human Ethics Committee, Mahatma Gandhi Medical College and Research Institute, Pondicherry, was obtained on November 30, 2015. All the procedures have been carried out as per the guidelines given in the Declaration of Helsinki 2013. Informed consent from all the study participant for participating in the study and sharing the data for research/publication purposes was procured.

Patients who were diagnosed clinically with acute ischemic stroke (WHO criteria)[12] within 24 h of onset as well as those with acute ischemic stroke confirmed by noncontrast computed tomography of the brain of either sex above 40 years of age were included in the study. Patients with hemorrhagic stroke, fever, sepsis, immune thrombocytopenia, and several renal diseases and with a history of anticoagulant, anti-inflammatory, or antiplatelet therapy were excluded from the study. [2],[12]

Of a total of 80 patients, 40 patients with acute ischemic stroke were selected as case and the remaining 40 individuals without acute ischemic stroke were taken as control.

Data collection

Sociodemographic characteristics of the patients such as age and gender and comorbidities including systemic hypertension, cigarette smoking, alcohol consumption, diabetes mellitus, and dyslipidemia were obtained from the patients' data files.

Individuals with an acute ischemic stroke were considered as Group 1 (case) and those without any vascular events were considered as Group 2 (age- and sex-matched control). Antecubital venous blood samples were collected from both the groups. Biochemical markers such as plasma glucose, blood urea nitrogen, creatinine, cholesterol profile, sodium, potassium, and chloride were examined periodically. For these tests, blood sample (5 mL) from each individual was centrifuged at 2000 rpm at 4°C for 10 min to obtain serum. In addition, 2 mL blood was collected in ethylenediaminetetraacetic acid tubes, and platelet indices (MPV and PDW) were measured within 30 min using the standard methodology template of Mindray BC-5200 auto hematology analyzer. The MPV and PDW values were then compared between the two groups.[13]

Statistical analysis

Data were analyzed using SPSS version 17 SPSS (Chicago, IL, USA). software. The comparison of mean and standard deviation between MPV and PDW was done using Student's t-test and Wilcoxon rank-sum Test. ROC curve was used to assess the cutoff points of MPV and PDW. P < 0.001 was considered statistically significant.

  Results Top

This study involved 40 patients with ischemic stroke and 40 patients without ischemic stroke, aged more than 40 years. It was noted that 31 case group patients and 26 control group patients had hypertension. The results also revealed that 30 case group patients had suffered a cortical ischemic stroke, whereas 10 had a lacunar ischemic stroke.

There was a significant increase in the MPV (fl) and PDW (%) in the case group as compared to the control group (P < 0.001). It was also noted that MPV and PDW in cortical ischemic stroke patients were increased significantly in comparison to lacunar ischemic stroke patients (P < 0.001) [Table 1].
Table 1: Comparison of mean platelet volume and platelet distribution width among the study groups and patients with different types of strokes

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The ROC curve revealed that the area under the curve (AUC) for MPV and PDW was statistically significant (P < 0.001) [Table 2]. The sensitivity (97%) and specificity were observed to be higher with MPV and PDW cutoff values depicting acute ischemic stroke [Table 3]. Moreover, none of the demographic comorbidities such as diabetes, hypertension, dyslipidemia, smoking, and alcohol consumption showed any significant difference in the MPV and PDW measurements [Table 4]. The logistic regression model revealed that for one unit increase in MPV, the log odds of having a stroke increased by 1.604 units and for one unit increase in PDW, the log odds of having a stroke increased by 1.047 units [Figure 1].
Table 2: Receiver operating characteristic curve based on the mean platelet volume and platelet distribution width in case group patients

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Table 3: Sensitivity and specificity of mean platelet volume and platelet distribution width at various cutoff points

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Table 4: Comparison of mean platelet volume and platelet distribution width among different demographics and comorbidities in case group

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Figure 1: Receiver operating characteristic plot depicting logistic regression model. (a) Receiver operating characteristic for mean platelet volume; (b) receiver operating characteristic for platelet distribution width

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  Discussion Top

Stroke is a manifestation of clinical symptoms of focal or global disturbance of cerebral functions. Although there are several studies related to the assessment of platelet indices in stroke patients, there is very limited literature on similar studies in patients from different ethnicities of India. Therefore, this study was conducted to determine the significance of platelet indices (MPV and PDW) and their measurement in acute ischemic stroke patients.[14]

This study depicted a significant increase in MPV and PDW in patients with acute ischemic stroke. This was in accordance with the study done by Bath et al. who observed that per femtoliter increase in MPV and PDW enhances the risk of stroke by 11%.[14] The AUC calculated from the ROC curve to determine the cutoff points was also in accordance with the previous reports. [15],[16]

In addition, the results of this study revealed a significant increase in platelet indices in cortical stroke patients in comparison to lacunar stroke patients, which was in line with the Uchiyama et al. study. This may be due to various factors such as shear-induced platelet aggregation and accentuated platelet function, which are very important in the pathophysiology of cortical stroke.[17]

A study done by Meena et al.[18] revealed that MPV and PDW were potential risk factors for acute ischemic stroke, which supported the findings of this study as well. The plausible reason for this could be the primary changes occurring at the bone marrow (megakaryocyte) level causing further activation of megakaryocytes, which is a feature of ischemic stroke.

The results of this study also revealed that there was no substantial difference between MPV and PDW in acute ischemic stroke patients along with various demographic comorbid conditions such as diabetes, hypertension, and dyslipidemia. Similar results have been obtained based on the differences in addictive behaviors such as smoking and alcohol consumption. [19],[20] Literature review also revealed that there was no statistically significant difference in the platelet indices across ischemic stroke patients with different comorbid conditions Abass,[21] which supports the results of this study. Furthermore, Biljak et al.[22] observed no statistically significant difference in MPV and PDW measurement between smokers and nonsmokers, as well as alcoholics and nonalcoholics.[23] Although these comorbid conditions influence or trigger the development of stroke, the difference in the values of platelet indices between the ischemic stroke patients and stroke patients with comorbid conditions depends solely on the type of condition, sample size of the study, and racial differences across different countries or regions.[23]

This study noted the involvement of MPV and PDW as biochemical markers in the onset of acute ischemic stroke, which are novel results of this kind in an Indian population. However, it has a few limitations. First, the sample size in this study was very small. Second, the severity of stroke was not assessed based on MPV and PDW values. The third limitation was that the follow-up of the recruited patients was not done to further assess the value of platelet indices at various time points. Therefore, keeping in mind all the above aspects, this study can be further extended to different races and age groups to confirm the role of MPV and PDW in the onset of ischemic stroke.

  Conclusion Top

MPV and PDW are potential biochemical markers of ischemic stroke and can be used for predicting the onset of acute ischemic stroke. The potential advantage of these markers is that they can be easily measured in a small quantity of blood sample.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Ciancarelli I, De Amicis D, Di Massimo C, Pistarini C, Ciancarelli MG. Mean platelet volume during ischemic stroke is a potential pro-inflammatory biomarker in the acute phase and during neurorehabilitation not directly linked to clinical outcome. Curr Neurovasc Res 2016;13:177-83.  Back to cited text no. 12
Sarkar RN, Das CK, Bhattacharjee U, Banerjee M. Platelet indices as a marker of severity in non-diabetic non-hypertensive acute ischemic stroke patients. J Assoc Physicians India 2018;66:40-2.  Back to cited text no. 13
Bath P, Algert C, Chapman N, Neal B; PROGRESS Collaborative Group. Association of mean platelet volume with risk of stroke among 3134 individuals with history of cerebrovascular disease. Stroke 2004;35:622-6.  Back to cited text no. 14
Del Zoppo GJ. The role of platelets in ischemic stroke. Neurology 1998;51 Suppl 3:9-14.  Back to cited text no. 15
Elsayed AM, Mohamed GA. Mean platelet volume and mean platelet volume/platelet count ratio as a risk stratification tool in the assessment of severity of acute ischemic stroke. Alex J Med 2017;53:67-70.  Back to cited text no. 16
Uchiyama S, Yamazaki M, Maruyama S, Handa M, Ikeda Y, Fukuyama M, et al. Shear-induced platelet aggregation in cerebral ischemia. Stroke 1994;25:1547-51.  Back to cited text no. 17
Meena P, Khare M, Airun A, Manohar,Saxena A. A study of platelet indices in patients of acute ischemic stroke. A prospective study. IOSR JDMS 2017;16:26-9.  Back to cited text no. 18
Boshnak NH. Reference intervals for platelet indices using sysmex XT-1800i in Egyptian population. Int J Med Health Res 2017;3:4-11.  Back to cited text no. 19
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Abass AE, Ismail I, Yahia R, Ali E, Mohammed R, Mohammed S, et al. Reference value of platelets count and indices in Sudanese using sysmex KX-21. Int J Med Sci Public Health 2015;3:120-5.  Back to cited text no. 21
Biljak VR, Pancirov D, Cepelak I, Popović-Grle S, Stjepanović G, Grubišić TŽ. Platelet count, mean platelet volume and smoking status in stable chronic obstructive pulmonary disease. Platelets 2011;22:466-70.  Back to cited text no. 22
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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