{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,19]],"date-time":"2026-10-19T07:44:16Z","timestamp":1792395856010,"version":"4.4.0"},"reference-count":24,"publisher":"Wiley","issue":"9","license":[{"start":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T00:00:00Z","timestamp":1789430400000},"content-version":"vor","delay-in-days":14,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T00:00:00Z","timestamp":1788220800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Brain and Behavior"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To evaluate the association between admission hemoglobin levels and in\u2010hospital functional outcomes in patients with acute hemorrhagic stroke in Pakistan.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Abnormal hemoglobin levels have an impact on cerebral perfusion and oxygen delivery to the brain, potentially affecting the recovery in stroke patients. Both anemia and polycythemia can impact neurological outcomes, yet evidence is not yet conclusive. This study examined the relationship between Hb levels, hemorrhagic stroke severity, and clinical outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design\/Methods<\/jats:title>\n                    <jats:p>\n                      A retrospective, multi\u2010center cross\u2010sectional study was conducted among adults admitted with acute hemorrhagic stroke. Hemoglobin levels measured within 24 h of admission were divided into three groups that are low (&lt;12 g\/dL in females, &lt;13 g\/dL in males), normal, and high. Patients with high hemoglobin [\n                      <jats:italic>n<\/jats:italic>\n                      = 1] were excluded due to insufficient sample size. The sample size was calculated using the standard formula for cross\u2010sectional studies at a 95% confidence interval and 5% margin of error. The minimum required sample size was 384 participants; however, 400\u2013450 participants were included to compensate for non\u2010response and incomplete data. Stroke severity was assessed using the NIH Stroke Scale (NIHSS) and functional outcome by the Modified Rankin Scale (mRS) at the time of discharge. Baseline characteristics were summarized descriptively. Group comparisons used Pearson\n                      <jats:italic>\u03c7<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      with Cram\u00e9r's\n                      <jats:italic>V<\/jats:italic>\n                      for categorical variables and Mann\u2013Whitney\n                      <jats:italic>U<\/jats:italic>\n                      or Kruskal\u2013Wallis tests for continuous or ordinal data. Multivariable logistic regression identified independent predictors of favorable outcome (mRS 0\u20132) and mortality, adjusting for age, sex, NIHSS, and comorbidities. Model calibration was evaluated using the Hosmer\u2013Lemeshow test and discrimination with Nagelkerke\n                      <jats:italic>R<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      . Non\u2010linearity was assessed using restricted cubic splines. NIHSS was retained as a core adjustment variable in all models.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      We included 445 stroke patients at discharge only (Hb\u2010low 330 [74.2%], Hb\u2010normal 114 [25.6%], and Hb\u2010high 1). Baseline severity and outcomes were similar by Hb group (NIHSS 9.74 \u00b1 7.02 vs. 10.64 \u00b1 6.25; mRS 2.15 \u00b1 2.20 vs. 2.25 \u00b1 1.78), with deaths 32\/330 (9.7%) versus 4\/114 (3.5%). Later hospital arrival was associated with higher mRS (\u03c7\n                      <jats:sup>2<\/jats:sup>\n                      p &lt; 0.0001) and mortality (\u03c7\n                      <jats:sup>2<\/jats:sup>\n                      p = 0.013). Diabetes (p &lt; 0.001), hypertension (p = 0.0001), and older age (p = 0.0049) were linked to poorer outcomes, whereas Hb category showed no difference in mRS (p = 0.257) or NIHSS (p = 0.195). In multivariable models, Hb (low vs. normal) was not independently associated with favorable outcomes (aOR 0.77, 95% CI 0.43\u20131.38, p = 0.378) or mortality (aOR 2.15, 95% CI 0.78\u20135.91, p = 0.139). NIHSS remained the dominant predictor (favorable outcome: aOR 0.77 per point, p &lt; 0.001; mortality: aOR 1.07 per point, p = 0.019), with diabetes also increasing death risk (aOR 2.58, p = 0.014). No evidence of non\u2010linearity was found [p = 0.41].\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Admission hemoglobin levels were not independently associated with in\u2010hospital functional outcome or mortality in this cohort. Stroke severity and diabetes were the strongest predictors of poor prognosis. Routine hemoglobin assessment remains clinically relevant, but targeted correction of hemoglobin may not directly improve outcomes in patients. Findings are limited to the in\u2010hospital period and should not be extrapolated to long\u2010term recovery.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/brb3.71715","type":"journal-article","created":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T07:34:59Z","timestamp":1789457699000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Association Between Hemoglobin Levels and Hemorrhagic Stroke Severity and In\u2010Hospital Outcomes: A Multi\u2010Centre Cross\u2010Sectional Study on Recovery and Prognosis in Pakistan"],"prefix":"10.1002","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-9334-850X","authenticated-orcid":false,"given":"Ayesha","family":"Johar","sequence":"first","affiliation":[{"name":"Khyber Medical University  Peshawar 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Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-7606-7071","authenticated-orcid":false,"given":"Aneika","family":"Ali","sequence":"additional","affiliation":[{"name":"Gomal Medical College  Dera Ismail Khan KPK Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-6741-7949","authenticated-orcid":false,"given":"Maryam Asghar","family":"Jamal","sequence":"additional","affiliation":[{"name":"Khyber Girls Medical College  Peshawar Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-5708-1283","authenticated-orcid":false,"given":"Maham","family":"Jawad","sequence":"additional","affiliation":[{"name":"Fatima Memorial Hospital and College of Medicine &amp; Dentistry  Lahore 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